MEDICINE SURGERY 

ONE 

INDUCTIVE SCIENCE; 

BEING AN ATTEMPT TO IMPROVE 
ITS STUDY AND PRACTICE, on a plan in closer alliance with inductive philosophy, 

AND OFFERING, AS FIRST FRUITS, THE 

LAW OF INFLAMMATION; 

ADDRESSKI) PARTICULARLY TO THE MEDICAL STUDENT AND THE PROFESSION, BUT EASY 
AND INTELLIGIBLE TO THE PUBLIC ALSO : 

THE WHOLE BEING THE INTRODUCTION AND FIKST PART OF 

A SYSTEM OF SURGERY. 
BY 

GEORGE MACILWAIN, 

FELLOW OF THB R. M. AND CHIR, SOC, ST RGEON TO THE FINSBURY DISPENSARY, CONSULTING 
SURGEON TO THE ST. ANN'S SOCIETY, ETC. 



"A cripple in the right way may beat a racer in the wrong." — Bacon, 
LONDON : 

S. HIGHLEY, 32, FLEET STREET, 



1838. 



PRINTED BY JOSEPH MALLETT, 
WARDOUR STREET, LONDOX. 



BY PERMISSION, 



TO HIS MAJESTY 

^ KING OF THE BELGIANS. 



May it please your Majesty, 

It is now nearly seventeen years since I became Surgeon 
to an Institution of which your Majesty is the kind Patron 
and a munificent Supporter ; I cannot forget the assistance 
which I derived from your Majesty's vote, both directly 
and indirectly, in securing that appointment. 

Strongly impressed with the conviction, that it is incum- 
bent on those who enjoy extensive fields of observation to 
render them contributory to the interests of Science, I have 
endeavoured to act in conformity with this conviction, so far 
as has been compatible with my ability, my other duties, and 
the too frequent interruptions of indisposition. 

The public are already in possession of several of my 
attempts in relation to particular subjects. The present work 
has objects of a more general and of a higher nature ; and 
it is in the hope that it may contain some evidence that I 
have not altogether neglected the opportunities placed within 
my reach, nor been unmindful of the support with which 
your Majesty was pleased to honor me, that I avail myself 
of the gracious permission of dedicating it to your Majesty. 

That your Majesty may long enjoy uninterrupted health 
and happiness, is, with sentiments of profound respect, the 
fervent wish of 

Your Majesty's 

Most devoted and faithful Servant, 

George Macilwain. 

London^ Argyll Place, Regent Street, 
January lOt/i, 1838. 



PREFACE. 



Before the reader peruses tlie following pages, I am desirous 
that he should have a general idea of the views and objects which 
have led to their publication. 

In common with many others of the profession, 1 have long 
been dissatisfied with the condition of the science, in the cultivation 
of which the greater part of my life has been employed. I have 
sensibly felt the humiliating conviction that medical science has not 
kept pace with other departments of knowledge, either as to its pro- 
gress or diffusion ; and that, as a consequence of this, it is encum- 
bered by many circumstances which impede its progress, abridge 
its utility, and derogate from the rank of those who follow it as a 
profession. 

We can in no way explain these circumstances by any refer- 
ence, either to the paucity of our facts (for of these we have 
abundance), or to any deficiency of industry, in at least a con- 
siderable number of the cultivators of medical science ; but it is 
easy to perceive that there is a great difference in the manner 
which has characterized our investigations, when compared with 
that observable in the cultivation of the other sciences. 

In these, there has been a pervading observance of inductive 
reasoning, as taught us by Lord Bacon : in medical science, we ob- 
serve as pervading a violation of it. I speak generally ; I do not 
mean that it is always observed in the one case, nor always disre- 
garded in the other. 

When we connect with the foregoing the fact that there is, be- 
sides, a very demonstrable correspondence in the progress of every 
science, and the observance of inductive reasoning in its cultivation, 
it is impossible to be otherwise than anxious to enquire at least 
whether the slow progress of medical science may not be attributable 
to that general disregard or violation of rules of reasoning which 
have so materially assisted the progress of all others. 



vi 



PREFACK. 



As regards any benetit derivable from the diffusion of know- 
ledge, medicine lias laboured under peculiar disadvantages. We 
observe a great difterence in the extent and nature of the ignorance 
of the public on medical and other matters. In general, ignorance 
consists in the simple absence of knowledge. In medicine, it is 
accompanied bj all sorts of error. 

Instead of being left in a condition in which men, under the 
influence of inclination or necessity, seldom fail to discover some- 
thing of the truth in nature, the public have been taught every 
variety of falsehood aad absurdity. Their passions, prejudices, and 
prevailing weaknesses, have all been excited in aid of every variety 
of quackery ; whilst the absence of information has left them with- 
out the smallest protection from imposition. To such an extent 
has this been carried, that the most successful quack almost ever 
known used to say that the secret of his success lay in the siaiple 
proposition — " Tell the public something in regard to medicine 
which common sense shews to be impossible." For the moment, 
we are astonished at the effrontery of such a confession ; and yet, 
if we look around us at the present hour, London alone furnishes 
too many exemplifications of the application of this precept : but 
we must not look for it alone in avowed empirics ; there is too 
much of regular as well as of irregular quackery. Teach the public 
but truth, they will become quick and intelligent detectors of all 
species of imposition : nor is this all ; by knowing how and what 
they are to observe, they will also become very useful assistants in 
scientific investigations, as I have already often experienced. 

It has been usual to attribute the low state of medical science 
to the difficulties attending its cultivation. I can in no way sub- 
scribe to this opinion. Like other sciences, it has its difficulties, 
both general and peculiar, doubtless ; but it has also great advan- 
tages. The difficulties of which we complain, as resulting from 
that interminable variety of form under which disease obliges us 
to investigate the laws of nature, shew how little we have wrought 
in the right way. Properly regarded, these varieties are of the 
highest utility : they are the strongest and most necessary tests of 
any law concerning which it may be our object to acquire ; and 
furnish ready to our hands, in countless forms of disease, varia- 
tions of conditions, which, in other sciences, we are obliged artifi- 
cially to institute. Besides which, it is only through the multiform 
yradations in disease, that we learn the true relations of this " nu- 



PREFACE, 



vii 



merous and dissimilar family whilst the verj diversity of cha- 
racter which they present produce this remarkable result — that 
those characters which they have in common (in all matters the 
most essential to know) stand out in stronger relief from the very 
diversities by which they are in different examples accompanied. 

My first object has been to point out some of the causes which 
have impeded the progress of medical science, and to expose some 
of the more prevailing errors ; then to collect a certain number of 
facts, and to conduct the consideration of them more in the spirit 
of common sense or inductive philosophy ; and to offer, as the first 
fruits of this mode of study, what appears to me to be nothing less 
than the " law of inflammation." 

I have here been, in one sense, breaking a new soil, and I am 
aware how poor the first harvest often is to those who do so : but 
the nature of the soil may be determined, its capabihties even as- 
certained ; although the more abundant produce may be reserved 
to future husbandmen, who, profiting ahke by the knowledge and 
mistakes of former cultivators, often discover improved modes of cul- 
ture, and derive more abundant crops with diminished labour. 

The task of improving any science is difficult ; but I am strongly 
impressed with the idea that truth has no character more striking 
than its simplicity ; that the discovery of it requires not extra- 
ordinary talent, so much as a plain, unfettered, and properly di- 
rected understanding ; and that, although the diffusion of truth varies 
in its progress, being always slow, yet in time it becomes es- 
tablished. Like hardy plants, it may thrive best in genial soils, 
but it will live in any. 

The motives with which I have put forth the work will ensure 
me from, any severity of disappointment. The size of the edition, 
and the price of the work, are such as render any pecuniary object 
out of the question ; whilst, had reputation, in any sense of the 
word, been my leading object, I should have pursued it much 
more auspiciously by the pubhcation of various matters more in 
conformity with prevaihng opinions, and (with the materials around 
me) requiring scarcely a tithe of the labour. 

I address myself chiefly to the medical student ; because it is to 
him that we must look for the advantages w^hich any improved 
mode of study may be ultimately calculated to produce ; in that, 
his faculties are less encumbered by preconceived errors — in the 
devotion of his time to the science — and in the longer period 
for observation which he will probably enjoy. I have thrown the 



viii 



PREFACE. 



whole into the form of Discourses, because, whilst this mode allows of 
a more familiar style, it enables me to employ that in which I have 
been accustomed to express m^'self. 

To many of the profession I look with hope and confidence 
that the suggestions herein contained will not be disregarded ; for, 
with respect to the position of medical science generally, I know 
that 1 am not singular, either in my views or anticipations. 

I am desirous, for reasons before mentioned, that the public 
should be informed ; and I should be vexed to feel that the book 
contained a single sentence which was not intelligible to every 
person of moderate education. I profess not, indeed, to instruct the 
ivhole mass; this, I think, cannot be done yet; — we must teach 
" down stream,"' as it were ; and, in time, that general intelligence 
will be diffused which can alone raise a glorious profession to that 
station which the high nature of its objects and its unquestioned 
utility alike deserve. 

1 have sensibly felt, however, the difficulty of addressing such 
different classes of readers ; that which seemed necessary to one 
class uHl sometimes appear tedious, or even puerile to others : but 
in teaching, I know not how this is to be avoided ; even in the h- 
mited audience of a medical school, the teacher, to instruct the 
whole, must often deliver that which is trite and wearisome to 
the better-informed. For the same reasons, 1 have not been able 
wholly to avoid repetitions ; but these, I hope, will be found unim- 
portant and excusable. 

The size of the volume (as in manuscript) has been consider- 
ably reduced, — 1st, by the omission of authorities, which would 
have increased its size and expense, and have made a parade of learn- 
ing without adding to its utility ; 2ndly, by reducing the description 
of the body, originally intended to have been given, to a very few 
general remarks, for which the object must be the apology ; 3d]y, 
I have not scrupled to omit, in aid of the reduction in size, many 
arguments and illustrations in support of the law of inflammation. 
Nothing would have induced me to do this but ihe following con- 
siderations : — I am much more desirous of exciting reflection, than 
of at once carrying conviction ; and the facts and arguments 
omitted will, from time to time, appear in connection with different 
diseases. I' am not in the least degree anxious that my views 
should be hastily adopted: nothing is more injurious than the 
reception of propositions \\ithout examination. If they be false, 
it perpetuates error; if tme, it abridges their utihty in leaving 



PREFACE. 



ix 



their principles unexamined, and thus narrowing the mode and 
extent of their application. 

As to the facts, I have endeavoured to select those which are 
either most common, most trite, or most indisputable. The con- 
clusions the reader must examine. I would advise the student and 
the general reader not to attempt more than one Discourse, at most, 
at one time ; and to peruse first the general observations on the 
body (imperfect though thej be), contained in the Appendix. I 
shall conclude this Preface with the following story : — 

It is said, that, in the family of the Sciences, MEDICINE was 
once afflicted with a certain " halt or lameness," which, whilst her 
sisters were yet young, did not deprive her of their society. As they 
grew up, however, she could scarcely ever accompany them in their 
various rambles into the fields of Nature ; and, when she did, she 
seldom brought home any of the i'ruits or flow^ers which they so 
abundantly gathered; so that she saw little society, and this too 
of an inferior description, beiug w^holly confined to a neighbouring 
family, the Arts. Various remedies had been tried for her relief ; 
all sorts of specifics from the animal, vegetable, and mineral king- 
doms of Nature. I know not how many thousand animals had 
been slaughtered in every variety of mode, and by every con- 
ceivable process of torture, in the hope of finding something that 
might throw light on the complaint under which Medicine 
laboured ; but all in vain ; until at length it was generally thought 
that her malady was incurable. At last, EXPERIENCE suggested 
to Reflection, that at one period the whole family had been in 
a very delicate state, but that their health and strength had been 
established by the employment of a remedy recommended by one 
" Bacon." They decided, therefore, that this remedy should be 
tried, and the treatment conducted, as it had been in the other 
cases, by Common Sense. 

At first. Common Sense met with great difficulty from va- 
rious members of her acquaintance : — Medicine had little faith 
in her skill, and AvARiCE, Indolence, and Prejudice were 
constantly interfering with her plans ; they would also often lead 
Industry away, when Common Sense most required her help ; 
whilst Education, whose assistance Common Sense highly 
valued, would frequently be absent. Notwithstanding all these diffi- 
culties. Common Sense proceeded, audit was evident that Medi- 
cine improved ; and as the improvement became marked, the sister 



X 



PREFACE. 



Sciences took a great interest in her case, and often furnished 
Common Sense with useful suggestions. As Medicine reco- 
vered, even Avarice and Indolence beheld her progress with 
satisfaction; and the scoffs of PREJUDICE were at length 
silenced. In the end, MEDICINE recovered, and when her health 
was restored, the beautj of her stately form was beheld by the 
whole family with admiration. MEDICINE now lived in harmony 
with her sisters ; and in the constant interchange of kindly offices 
in their respective labours ; but, as might be naturally expected, 
she looked up with most reverence to her benefactors, Common 
Sense, Experience, and Reflection. 



INDEX. 



DISCOURSE I. 

PAGE 

Surgery a iDranch of Natural Philosophy - - - - - 1 

Not an abstract science. This notion has been injurious - - - 3 

Its relation to other sciences - . . . _ - 4 

Medical Science — Definition — What Art is - - - - - 6 

Anatomy, its importance impressed - - - - - 8 

Morbid Anatomy useful, but only one element in Pathology - - - 10 

Medical Science rests not exclusively on Anatomical foundation - - 12 

The relative progress of Anatomical and Medical Science considered - - 13 

Celsus — Modern state of Science - - - - - - 14 

Anatomy has closer relations to some parts of Sm'gery - - - 15 

Position of a Surgeon considered - - - - - - 16 

Science best cultivated by observation of obvious Phenomena - - - 17 

This considered in relation to some other sciences — Astronomy - - 18 
Optical Instruments, Botany, Pneumatics, Electricity — Whewell quoted in 
support of - - - - - - - --23 

Illustrations of the value of observing obvious phenomena, as distinguished 
from minute objects, in regard to Medical Science — Circulation of the 
blood — Harvey — Father Paul — Sylvius — Michael Servetus — Realdus Co- 
lumbus, &c. - - - - - - - -25 

John Hunter, his improvement in the treatment of aneurism - - - 26 

Mr. Abernethy, his views founded on simple phenomena - - - 28 

How to conduct observations - - - - - - 29 

To avoid preconceived notions - - - - - - 32 

Influence of Authority — Motives of submission to it examined - - - 33 

Successful observers to be studied - - - - - _ 34 

Remarks on the relation of facts and conclusions - - _ _ 35 

Neglect of these considerations in Medical Science exemplified - - 37 
Accidental opportunities of testing received notions never to be neglected; 
with illustrations - - - - - - __40 

Further tests of relation of facts and conclusions — Illustrations - - 43 

Complexity in prescription deprecated - - - _ _ 45 

Of reasoning on probability — Analogy - - - - - 46 

Experiments on living animals as scientifically unproductive as they are 
in a moral sense questionable - - - - - - 48 — 50 

Spallanzani — J. Hunter — Sir C. Bell — Spurzheim — Phrenology, as a science 

of observation, considered - - - - - _- 5i 

Consideration of Experiments on Animals resumed - - _ _ 54 

Paley - - . ------ 55 



xii 



INDEX. 



Undue reliance on external senses in scientific pursuits a cause of error — 
their proper function in such, matters considered - - - - 56 

Lord Bacon quoted in support - - - - - - 58 

Concluding remarks on Analogy — Mr. Abernethy - - - - 59 

Qualifications of Medical Practitioners — Operations, the undue importance 
attached to their performance . . . . . 60, Gl 

Friendly hints to Students — The dignity of the Profession — its duties — the 
motis'es which should determine the choice of it - - - - 64 

Our conduct to each other to be courteous and liberal, but not to support vio- 
lations of propriety - - - - .--65 

Recapitulation - - - - - - ._67 



DISCOURSE II. 

Life — its definition — what is it? - - - - - 09 

Objections to this question untenable — its investigation useful in ridding us 
of false hypotheses - - - - - - 72 

Our right and our duty to examine, inferred from the possession of powers 
adapted for it — the use of this power one thing, its abuse another. — Life, 
jomcif/ca^/y, the law of existence in all things - - - - 73 

Common properties of Matter - - - - - 74 

Divisibility, expansion, attraction in proportion to distance - - - 75 

Analysis of water — elective affinit}' — Elasticity — Analysis of chalk — Vege- 
tables — Properties in common — peculiar, air, light, moisture - - 78 

Animals, analogies vrith vegetables — Motion, differences indifferent animals 
— Senses, circulation, respiration, modified in different animals — Phenomena 
different ; governing principle may be the same - - - . 80 

What is this principle? — (JSote on Materialism and Immaterialism) — Va- 
rious names given to it of no import — That it depends on organization 
more tangible but erroneous ; why ? — The idea of life being superadded to 
organization, equally untenable ; why ? — Hunter — Abernethy - - 84 

Principles in universal operation not probably unconnected with animal life. 
Different existences being more perfect, or more beautiful than others, 
erroneous expressions — They may be subordinate - - - - 87 

The pervading influence of Electricit}- — Examples — Its effect on gra^-itation ; 
on chemical affinity ; on vegetables ; on animal life — Analogies of, with 
Electricity' — Torpedo - - - - - - 88 

These facts do not prove that Electricity is Life ; and the Torpedo seems to 
prove the contrary, in shelving that Electricity is subservient to the vital 
principle - - - - - - 91 

There may be principles altogether unknown to us — Electricity' but a modern 
discovery — Note on Heat — Whatever regulates it and Electricity, a 
link nearer, at least, to life than either of these principles — Recommenda- 
tion to study Phenomena ; the most likely thing to advance our knowlegde, 
whilst it is essential to any increase of our professional acquirements - 93 

How to observe. Air, Heat, Moistiire, Food, Moral Causes ; also how Na- 
ture relieves the body ; the latter not sufficiently observed, though highly 
promising of further knowledge — Preservative power limited, but how ? - 94 



INDEX. 



xiii 



Note, recommending investigation in regard to habits, countries, climates, 
and different epochs - - - - - - -96 

How the occasional coexistence of health and enjoyment w'ith functional 
disorder are to be explained — Preservative powers of Nature ; why they 
require assistanoe — Death (time apart) sometimes from the direct influence 
of injurious causes; more generally, from the state of the body at the 
time — Savage life ; diseases few — Civilization, effects of — Conclusion - 97 

DISCOURSE III. 

Consideration of the living body that to which all other studies are subser- 
vient — Sympathy very important — Mr. Hunter, Dr. Whytt, Dr. P. 
Wilson, Dr. "Wilson of Kelso, and Mr. Abernethy, all regarded it with 
especial interest — Sympathy a practical Physiology — Plan proposed — Sym- . 
pathy, whatP — familiar illustration — The circumstance of a man feeling 
his toes after amputation explained — Eye and Ear — Analogies — Pheno- 
mena of Volition — Tortoises — Case — Primary object in collecting facts, 98 

Skin one of the portals of the body — Sympathy between its several parts — 
Cold, Heat, Clothing, Stimulants, Blisters — Skin, as affecting other parts ; 
head, throat, fauces, stomach, and bowels (Note on Mr. Hunter) ; these 
reciprocal, as are all sympathies whatever — Skin affects respiratory organs, 
trachea, bronchia, lungs ; also circulating, as heart - - - 115 

Skin affects liver, kidney, bladder, urethra, covering of the lungs (pleura), 
and of the bowels (peritoneeum ) - - - - - 120 

Skin affects parts immediately beneath it — Skin affected by the mind ; blush- 
ing — Remarks on the neglect of the skin - - - - - 122 

Sympathy between skin and muscles, bone, ligaments, fascise - - - 123 

Digestive organs, teeth, salivary glands, alimentary canal, with the head, 
heart, and lungs - - - - - - --124 

"With the liver, pancreas, urinary and genital organs - - - - 1 35 

DISCOURSE IV. 

SYMPATHY CONTINUED. 

Alimentary Organs, with Uterus - - - - - -144 

with Spinal Marrow — Cases illustrative of, also of Liver 

and Heart ----- . . 149 

Liver with Head — Spleen and Pancreas - - - - - 162 

Heart, Sympathies of, primarily considered ----- 167 

Uterus primarily considered - - - - - -l7l 

Tendon — Bone — Structure of Joints generally - - - - 174 

Muscles — Cellular Tissue - 176 
Brain — Mind - - - - - - - - 182 

DISCOURSE V. 

USES AND APPLICATION OF THE PHENOMENA OF SYMPATHY. 

Require a work devoted to the subject — Compensating Influences of Organs 
— their application in treatment illustrated — Purgatives not the best mode 
of opening the bowels — Cases. — Application of Mental Sympathies — Illus- 
trations. — Summary of the conclusions deducible from the phenomena of 
Sympathy. - - - - - . . - 190 



xiv 



INDEX. 



DISCOURSE VI. 

ON INFLAMMATION. 

Mr. Hunter's distinctions of injury and disease erroneous — Terminations of 
Inflammation shortly defined — Inflammation as occurring in the simplest 



form of injury, as producing different results . . _ . 220 
Of pus — Serious consequences related as occurring after wounds, occur 

also without any wound — Abscess - - - - 228 

Mucous and Serous Membranes - - - - - - 234 

Adhesion — Suppuration — Ulceration - - - - - 238 

Mortification — Thickening - - - - 247 

Summary of Phenomena so far collected - - - - - 256 



DISCOURSE VII. 

OF THE IMMEDIATE CAUSES OF THE APPEARANCES OF INFLAMMATION, 
COMMONLY INCLUDING THE " PROXIMATE CAUSE," AS IT IS TERMED. 

Discussion unprofitable — Obvious Phenomena shew what is useful — Too much 
stress laid on this ; the real question is, what causes Inflammation as a 
whole ?— M. Kaltenbrunner - - - - - - 259 

Bleeding founded on narrow A-iews of the subject - - - . 261 

DISCOURSE YIII. 

OF THE REAL CAUSES OF INFLAMMATION. 

How injurious agents are generally got rid of — Number of processes occur- 
ring on the surface remarkable - - - - 270 
Remarks on those occurring on continuous surfaces . _ _ 275 
Mucous Membranes — Eye - - 279 
On apparent exceptions to a law - - - - _ _ 283 
Law of Inflammation proposed - - - - - 285 
G-out — Scrofula — Boil — Carbuncle — Anthrax ; in connection with the Law 

of Inflammation - 286 et seq. 

Erysipelas ; its connection — Retrospect of Cutaneous Diseases - 298 et seq. 
Recurrence to common Inflammation - - - - 302 

All Inflammations connected with Disorder of the System . _ . 304 
Further reasoning on Inflammation — The quantity' of blood no necessary 

connection with the Induction of Inflammation - _ . _ 305 

How Nature bleeds, and why — Examples considered - . _ 313 

What determines the blood to particular parts ? — Considered - -323 

DISCOURSE IX. 

REMARKS ON ULCERS, FISTULA, AND TUMOURS, IN RELATION TO THE 
LAW ENUNCIATED ; ALSO ON CERTAIN APPARENT EXCEPTIONS TO THE 
LAW, AS PRESENTED IN JOINTS, VEINS, THE EYE, ETC. 



Ulceration, a particular function .... 333 et seq. 

Fistulse, continued suppuration, why ..... 342 

Tumours - - - - - - ... 347 

Joints — Eye^ — Veins - - - - - 349 et seq. 

Specific Diseases in relation to the Law - - ... 362 



INDEX. 



XV 



DISCOURSE X. 

TREATMENT. 



In all diseases, the object is to remove the cause - - - - 369 

These briefly reviewed — Objects detailed - - . _ - 371 

Treatment described - 373 et seq. 

Cases in illustration - - - 374 

Case of pure Inflammation ------- 385 

Treatment considered generally - - - - - - 394 

Evacuation of the Bowels ; — Bleeding, General — Local - , - - 402 

Purging - 404 

Of Tartrate of Antimony, &c. ------ 407 

Of measures applied to the surface — Blisters, Setons, Issues — Warm and 

Vapour Baths - ------- 409 

Of Mercury in Inflammation — its power — the mode of its action explained - 415 

DISCOURSE XI. 

ON ERYSIPELAS. 

General description - 426 

Nature of Erysipelas — an interesting link in inflammatory processes • 428 

Some points in its Nomenclature — Pearson — Dessault — Lassus — Baron 

Boyer — Hutchinson — Lawrence ------ 430 

Recognition of its connection with general disturbance - - . 432 

Remarkable case -------- 435 

Another in illustration - - - - - - 439 

Further remarks on its constitutional nature, and its connection with biliary 

disorder — Not confined to disturbance of this function - - - 441 

Does Erysipelas occur in internal parts ? - - - - - 442 

Is it contagious ?-------- 444 

Remarks on Inflammation of Absorbents, and the consequences of wounds 

received in dissection — these not generally from absorbed poisons - - 446 

Dr. Butter — Professor Dease— Sir A stley Cooper - 450 
Mr. Abernethy — Author's Case ------ 452 

Treatment of Erysipelas considered — Cases — Treatment resumed - - 465 

Of Bleeding — Remarks on Mr. Lawrence's Cases - - 467 et seq. 

Author's Experience on Erysipelas ------ 474 

Local Treatment — Incisions, &c. — Hutchinson, Lawrence - - - 477 

Of local measures in aid of the prevention of Erysipelas - - - -480 

A Summary of the Discourse - - - - - - 482 

Erysipelas — the coexistence of great excitement with little power, &c. 

DISCOURSE XIL 

OF BOIL, CARBUNCLE, ANTHRAX, BURNS, ETC. 

Boil, Carbuncle, and Anthrax, described - . . . „ 485 

Treatment — Cases . _ = . , . 439 ^t seq. 



xvi 



INDEX. 



Burns - - - - - - " - - 496 et seq. 

Their nature considered — essentially to be regarded as severe injuries to an 
important organ — to dismiss the idea of heat acting as a peculiar principle 
— illustrations from other injuries — Dr. Kentish - - - - 505 

The Treatment of Burns and all severe injuries — in principle the same - 505 
Of the contraction of the scars in severe Burns — Treatment of - - 511 

Summary - -- -- -- -- 514 



APPEXDIX. 



Of Assimilation — what - - - - - - -519 

Of Digestion — Absorption ------ 520 et seq. 

Of the Circulation - - - - - - - 525 

Of hydraulic influences in the conduct of - - _ - 52/ 

Of the functions of Absorption 533 
Of tbe means by vrhicli old materials, &c. are thrown off from the body - 534 
Of different structures — of Bone, Joints, Muscles - - - . 536 

Of Membranes — of Cellular Tissue ----- 543 et seq. 

Of the Nervous System - - - - - - -54/ 

Conclusion — the Author's reason and apology for the very limited sketch of 
the body --------- 550 



MEDICINE AND SURGERY, 



REGARDED AS 

ONE INDUCTIVE SCIENCE, 

ETC. 



DISCOURSE I. 

Surgery is to be regarded as a brancli of Natural PMloso- 
pliy ; it has well-marked and interesting relations to most of tlie 
other departments of Science, and more or less of connection 
with them all. The sustained impression of this connection is 
important. It facilitates the acquisition of that which is already 

ERRATA. 

Preface, page G, for acquire read enquire 

£0, for this investigation read this inA-ention 

34, for more learned read mere learned 

73, for travels at a thousand rt-ad a hundred and ninety-five choasand 

119,y«/- change the function read derange the function 

273, for found in other departments read advantageous in other departments 

352, for description of cure read description of case 

480, for enlarged surface read exposed surface 

artificial. The sciences have all one object in common ; that 
is, the interpretation of the laws of nature : and as all these 
laws exhibit mutual connections, it follows, that all the inves- 
tigations, of any of them, inasmuch as they have for their ob- 
ject to explore the particular relations of particular parts of these 
laws, should embrace the recognition of the general connection 
which such parts have with the whole. 

The idea that Surgery is a sort of abstract science, is false, 
and therefore injurious. This notion, and others equally erro- 
neous, have so effectually retarded the progress of medical science, 
as to render it the lowest in the scale of impro'uement. It will be one 
object of this discourse to point out some of the causes of this 
inferiority, and to recommend attempts for theii' removal. So far 
is surgery from being an abstract science, that there is no one 

B 



2 



which it would be more impossible to isolate from general philo- 
sophy. In 110 one branch of human knowledge do we find 
evidences of that connection which exists between it and all 
others more obvious, more intelligible, or, indeed, more striking, 
than in surgery. The more we extend our views into the various 
departments of natural philosophy, the more are we struck with 
their mutual connection ; so true is this, that we arrive there- 
from, at one of the most sublime truths deducible from natural 
evidence. We are carried, from contemplating the universal 
relation of so many particular instances of design ; to the conviction 
that they all emanate from One x\lmighty Creator. Not only, 
therefore, is surgery not an abstract science, but there is in reality 
no such thing. The notion is a dream of error, an idol of the 
mind, as Lord Bacon would call it, which must be removed on 
the very threshhold of our studies. This, like other errors, results 
from a habit of restricting our observations to the several relations 
observed between the different parts of any one subject to the other 
parts of the same subject ; but this should be regarded as the ulti- 
mate endy not as the sole inode of enquiry. Lord Bacon observes, 
" No man can discover the nature of a thing, in that thing itself, 
but the inquiry must be extended to matters more in common." 

To conceive that man, or any thing which relates to him, should 
be otherwise than in connection with the various laws governing 
the world he inhabits, is not only exceedingly difficult, but, on 
reflection, will appear to be to the last degree improbable. But the 
difficulty or improbability becomes nothing less than an absurdity 
when such a supposed isolation is referred to his body, a part 
which he possesses in common*, which he holds by a similar 
perishable tenure with other countless multitudes in the creation ; 
these again forming fresh connecting links in the chain of material 
existence. I here allude to that gradation which is plainly ob- 
servable in the different tribes of animals, and is continued through 
the vegetable, even to the mineral kingdom of Nature. If we 
expected any thing in man to be governed by peculiar or specific 
laws, the enquiry would be more auspicious if directed to some 
distinguishing peculiarity; the more striking, the better for our 
purpose. The mind, in fact, would appear a much more likely 
instance than the body. 



* I here only allude to that assemblage of functions which constitute his pre- 
sent existence, and which are obviously adapted to his present condition. 



3 



But if tiie contemplation of the mind> as contrasted with the 
consideration of the bodj, appear to favour the idea of abstract 
and peculiar laws of government, and if that examination which 
detects connection every where else should appear to fail in esta- 
bhshing corresponding relations here, — still the simple fact that 
it is this Mind which enables man to comprehend all, or indeed 
any, of his relations to the globe in which he lives, would of itself 
be sufficient to correct any idea of disjunction. It is true that we 
discover enough in the mind to shew that it is peculiar in its at- 
tributes, that it thinks, compares, judges, that it possesses, and feels 
the possession of higher powers and more exalted destinies than 
are accorded to the rest of the creatures of this planet: it is true 
that the convictions thus arising from something in its own 
elements are confirmed by higher authority, and that, whilst 
the Creator has spoken to other things by laws only, he has 
spoken to the mind of man both in laws and by direct communi- 
cation ; j'-et I say, notwithstanding all this, whilst the mind 
resides in, and is connected with matter, we trace numerous con- 
nections between it and other creatures, in the analogy observable 
between the instincts and propensities of animals, and the passions 
and feelings of Man. 

But, to return. The notion of Surgery being an abstract 
science, limits the enquiries of its professed student to that accu- 
mulation of details to which the term practical is usually applied, 
such as Anatomy, Physiology as arising out of it, mechanical opera- 
tions, and the use of remedies. It tends to preclude any enlarged 
enquiry into the laws of which diseases are but the exemplifica- 
tions, and debars the science from that light which would otherwise 
be imparted to it by the minds of thousands of philosophically 
minded men, who are deterred at present from venturing on sub- 
jects, hitherto represented to them as appertaining to a specific 
study. In regard to the connections of medicine and surgery with 
other sciences, it will be sufficient, in this place, merely to mention 
Anatomy, Physiology, Chemistry, and Botany ; whilst the relation 
which the eye has to light, the ear to sound, which respiration and 
circulation bear to the laws regulating the pressure or motion of 
aeriform or other fluids, the mutual adaptation of various parts of 
the body, to mechanical principles ; or the forces acting on the 
body, either in relation to parts or the whole, to other depart- 
ments of knowledge, illustrate the connections of surgery with 
optics, acoustics, pneumatics, hydraulics, mechanics, &c. respec- 



4 



tively. Chemistry has still more interesting relations than those 
which belong to it in a pharmaceutical sense. Philosophical chemis- 
try, in unfolding to us various laws observed in the composition of 
tangible substances, materially assists us in forming some idea of 
organization ; whilst, in giving us some notion of the minute divi- 
sibility of matter, it enables us to apply it in the consideration of 
taste and smell ; and the electro -chemical brancih of the science 
has opened to us a wide iield for enquiry concerning secretion, 
excretion, and the relations which subsist between the chemistry 
of what is called unorganized nature and that of animals. The 
sciences which relate to variations of temperature or of climate, 
or to the causes, whether local or general, whereou these depend, 
are also intimately comiected with medicine. 

The circulation of the blood is conducted with a very evident 
observance of the laws of hydraulics ; and thus a knowledge of the 
laws observed by fluids, when in motion, enables us to comprehend 
the beauty of many arrangements in the blood vessels which, 
without such reference, would be unintelligible. A vast number 
of very cruel experiments on animals have only tended to develope 
what the most simple application of the elements of hydraulics 
would have made certain without any such modes of experiment. 
Haller " On the Circulation," &c. But whilst thus the study of 
hydraulics explains many circumstances in the distribution of the 
circulation, it is more than probable that the examination of the 
circulation, with this view, would unfold to us some, perhaps many, 
improvements in hydraulics. 

Mathematics may be made of great use in that part of natural 
philosophy which has direct bearings on medicine : they should 
also assist in disciplining the mind to a close method of reasoning ; 
but, practically speaking, as regards our own profession, they are 
seldom found to achieve the latter object. They are apt, by accus- 
toming a man to one kind of demonstration, to disqualify him 
from obtaining conviction from any other. The mathematician 
has his science of unknown quantities ; so there is also a kind of 
algebra in natural philosophy : but the one mode of reasoning leads 
to a result apparently certain and demonstrable ; the other always 
keeps the mind humble and enquiring, and, in conducting it even 
to the most lofty conclusions, presents to the mathematician a 
doctrine rather of probability than of demonstration. I need not 
say that the natural philosopher thinks otherwise. I here only 
speak of ordinary mathematical attainment, and its most commonly 



5 



observed effect. I do not mean to deny the power which mathe- 
matics have of being really applied to the purposes of the na- 
tural philosopher ; I only say that, in regard to medical science, 
such an application of them is seldom made. In fact, I have not 
often found that a mathematician is a very acute reasoner in na- 
tural science : but I speak of the mass, and not of a few distin- 
guished individuals who convert mathematics to the higher ends 
which they are calculated to serve*. 

But I here only cursorily mention the relations of medicine 
to the other sciences. These will be more particularly dwelt on 
in connection with the various subjects to which they are more 
especially applicable, and which will therefore more nsefuUy im- 
press them on your recollection. I have said that medicine is 
behind the other sciences, and that one of my objects will be to 



* Mathematics : — The unknown quantities of the natural philosopher are the 
laws of Nature — he requires a datum like the mathematician ; and, to reason, not 
less demonstrable than are mathematical data to the senses. The data assumed 
by the natural philosopher are, that every thing is formed in the most perfect adap- 
tation to the uses for which it is designed, and that in the execution of these func- 
tions it is governed by certain laws. So far the sciences, I conceive, commence on 
grounds equally secure, to say the least of it. But the proceeding onwards of 
mathematical and natural philosophy are very different. With a view to incul- 
cate the vast importance of observing obvious phenomena, it will be my object 
presently to shew that the most important advances in natural science have re- 
sulted from such sources. But mathematics are a different thing. It is possible, 
I conceive, for a man to be in some sort a mathematician without having scarcely 
observed natural phenomena at all. There are no phenomena whence Xhe primary 
truths of mathematics are wrought by inductive reasoning, which is the very soul 
of natural philosophy. In mathematics a thing is supposed to be so and so, 
because the external senses preclude the possibility of conceiving it to be other- 
wise ; and then its relations of time, quantity, &c. are wrought out by a particular 
exercise of an intellectual faculty : thus arise certain additions to the original 
datum, developing not only certain times, numbers, or quantities, but also certain 
characteristics which they have, which may be termed, perhaps, the laws of their 
several relations or proportions. Regarded in this condition of development, the ~~ 
science becomes of material assistance in the interpretation of Nature ; for if once 
any phenomenon in Nature can be made to refer to any definite relations of number 
or quantity, the mathematician can then ask questions, as it were, of Nature ; in 
other words, he can experimentalize on the application of a law, or the appearance 
of a law in any one phenomenon, to the explanation of other phenomena whose 
laws are yet unknown. In this way mathematical science becomes an engine of 
great power, in combination with an inductive reasoning ; but in its origin it obtains 
nothing from the observation of the phenomena of nature It in some sort pre- 
cedes this, and may be regarded as an instrument, powerful, but extraneous. 



6 



point out some of the causes by which its progress has been re- 
tarded. But to enter into these as separate subjects, would lead to 
a verj inconvenient digression ; and I hope to make them suffi- 
ciently intelligible whilst I am endeavouring to shew you how you 
should proceed in the study of our profession. In the first place, 
however, let me say a few words on the definition of surgery and 
medicine. It is difficult to drive from the mind established notions ; 
yet, if they be erroneous, to do this is essential to the inculcation 
of truth. The usual definition of medicine and surgery favours 
the idea of an abstract science. It is said, of both medicine and 
surgery, that they consist in studying the nature and cure of 
diseases. I object to such a definition ; not because it is not 
true, but because it does not convey the whole truth ; it is, in fact, 
imperfect. 

Medical science is, in fact, the study of the laws and relations 
of animal bodies, in order to ascertain the modes in which Nature 
relieves diseases or repairs accidents ; and to determine the condi- 
tions of the whole body, which favour or impede these processes 
in its various parts ; with an especial view, in the one case, to the 
maintenance of such conditions ; in the other, to their removal. 
The achievement of this point is the common object of medicine 
and surgery. Surgery is sometimes called an art. If it be an art, 
however, it is one of the lowest description ; inferior indeed to the 
most ordinary handicraft. As well might you call astronomy an 
art, because it requires the adjustment of optical instruments. 
Surgery is never an art but in consequence of its imperfection as a 
science ; and even then it is one of very simple character. As an 
art, and one that can be acquired in less time than any other with 
which I am acquainted, it will remove a stone from the bladder, 
will tie an artery, or will amputate a limb. But, as a science, it 
w^ould prevent the formation of the stone, the changes in the coats 
of an artery, or the forces of the circulation which produced the 
aneurism, and put a stop to the morbid actions necessitating the 
removal of the affected member. Even where the idea of art 
is most obtrusive, as in fractures and dislocations, so various are 
the influences derived from the condition of the body at the time 
of their occurrence, that where Nature requires any assistance 
beyond replacement of the parts, it is altogether scientific ; and 
although operations are mechanical, yet their success depends 
on general principles of treatment which have reference to the state 
of the body, both before and after their performance. Neither 



7 



can the replacement of broken or dislocated parts be fairly called 
an art ; since a ^eat deal will often depend on a knowledge of the 
laws of muscular action, and of the means bj which the impedi- 
ments afforded thereby are best overcome or evaded. 

In thus contending that surgery should be regarded as a 
science, it is necessary to observe that I speak more with reference 
to what it must necessarily be as a branch of natural knowledge, 
than to any actual possession which we have of such knowledge. 
But if we regard it as one department of medical science, humble 
though its pretensions may be, they appear to me to be superior 
to what is called medical science, in popular contradistinc- 
tion to it. The difference between an art and a science seems 
to be essentially this : — an art consists in the knowledge of 
certain means by which we can produce certain effects ; but 
without our understanding the principles on which they depend, 
or, in other words the laws of Nature, of which they are the 
necessary exemplifications. A science consists in the know- 
ledge of a certain number of phenomena, and the power of 
referring such phenomena to the laws by which they are go- 
verned. Galileo's pump exemplifies the art, our own pumps the 
science ; though the mechanical construction be the same. In this 
sense, medical science, — I here include in that term both medicine 
and surgery, — are at so low a point, that their claim to be considered 
sciences at all, in relation to our actual knowledge, becomes almost 
questionable ; but surgery seems to me to approach the character 
of a science much more nearly than other branches of medicine ; 
and this, not because it is easier, as has been somewhat infelici- 
tously asserted by a modern writer, but because it has, so far at 
least as Mr. Hunter is concerned, been cultivated in a more philo- 
sophical manner ; that is, by observing what Nature does in 
repairing injuries, &c. and by founding our proceedings, if not on 
her laws, at least on their proximate proceedings. Herein lies the 
beauty of most that Mr, Hunter did, which has proved really 
useful ; and which has led to a certainty and uniformity in 
many surgical matters which we do not find in the practice of 
medicine. For example, if I wish to heal a wound now, I evidently 
found my proceedings on what I know to be Nature's processes, 
and my measures are confined to the removal of what must ne- 
cessarily retard or prevent her operations ; but if these expedients 
refer to any thing but local circumstances, if I am, in short, 
obliged to refer them to the general condition of the animal, I find 



8 



that medical science bj no means affords data to reason on, cor- 
responding to those which surgery has deduced from previous 
investigation of the processes going on in the part. 

I need scarcely observe, that the ultimate end of the studies of 
the surgeon is to understand the laws of disease ; and this of course 
he cannot do unless he comprehend the natural functions of the 
body. Now, in all bodies whatever, there is found to be a certain 
connection between their structure, or the arrangement of their 
parts, and the phenomena which they exhibit ; and in none is 
this connection more important than in animal bodies. Hence 
the knowledge of this structure becomes a point of primary im- 
portance ; and this, in regard to animals, constitutes the science of 
Anatomy. 

You will easily comprehend the importance of this science, 
when I tell you that the various interesting relations which are 
observed between the structure of animals and their several func- 
tions, have even led certain men to believe that life itself was 
nothing but a consequence of certain structural arrangements. 
This idea, which I believe to be very erroneous, as I shall en- 
deavour to shew you in a subsequent discourse, I merely men- 
tion here for the reason I have stated. But many other consider- 
ations evince the importance of anatomy. How are you to judge 
of the seats, much less the causes of diseases, unless you know 
not only where the affected parts are situated, but unless you are 
acquainted also with their several anatomical relations ? 

In surgery, — and I here speak of a branch of medical science 
which, however humble its present pretensions, appears to me 
to have advanced beyond every other, — anatomy becomes in the 
highest degree necessary. Though, with the advancement of 
scientific knowledge, the number of occasions for operations has 
sensibly diminished, still there are many diseases which our igno- 
norance obHges us to remove, and others, which not being able to 
prevent, we relieve by operative proceedings. 

Now, to attempt to remove a limb, to take a stone from the 
bladder, to tie an artery without including the vein or nerves 
which accompany it, or to remove tumors often involving more or 
less of important structures which must be interfered with as little 
as possible ; I say, to do all or any of these without a clear know- 
ledge of the parts on which we are operating, is a thing so ob- 
\'iously fearful, that no man in his senses would think of attempting 
it. But, besides, there are various symptoms accompanying 



9 



almost every malady, which it is impossible to understand without 
knowing the anatomical relations of the several parts in the in- 
terior of the body; whilst, with such knowledge, many, I had 
almost said most of them, become intelligible. 

Neither should a student be satisfied with a mere general 
knowledge of the subject, such as will enable him to pass the 
ordinary examinations ; he should be perfectly acquainted, not only 
with the origin and course of vessels and nerves, the connection 
of the several viscera and their various relations, but he should 
also be well informed as to the distribution of the various tissues 
of the body ; for he will otherwise never obtain a clear notion of 
the elements of which the body is composed, nor will he arrive at 
any useful application of anatomy or physiology to pathology, or 
the doctrine of disease. A good general knowledge of the subject, 
such as would save him from egregious error, such as would enable 
him to understand the general principles of medical science, might 
certainly be obtained without involving acquirements so extensive 
as the above ; and I wish the public were in possession of such know- 
ledge, since its attainment is easy, and since, by enabling them to 
discriminate between men of information and those who were ignorant, 
it would he a far better security than any legislation can give, not only 
against avowed empiricism, but all other kinds of quackery. But the 
medical practitioner who should be content, through indolence or 
supineness, with this kind of knowledge, would be in the highest 
degree culpable, and could not undertake the responsibility with 
which he is often invested without a reckless absence of principle. 

A very important branch of anatomy consists in the knowledge 
of those changes which are produced in various organs by the 
influence of disease. This is what is called morbid anatomy. Now 
diseases frequently produce changes of structure in organs, destruc- 
tive of life ; and even where the change is not of a kind or extent 
sufficient to destroy life, yet it is found materially to modify the 
phenomena on the subsequent occurrence of disorder ; frequently, 
in fact, rendering disordering influences fatal, which, when they 
operate on healthy organs, are found to be of trivial importance ; 
and thereby rendering it necessary that the treatment should be 
materially modified in the two cases. The greater danger attend- 
ing disordered action, occurring in an organ previously diseased, 
results sometimes from the direct influence which it exerts on the 
whole economy, sometimes from an indirect agency, in the greater 
tendency which it has to derange one or more organs in addition 



10 



to that primarily affected, iu a manner more particularly to be 
dwelt on when I have to speak of what we call the Sympathies of 
the body. You will perceive, by the foregoing, that morbid ana- 
tomy must also have ver}- important bearings on oar power of dis- 
tinguishing the seats of various disorders (diagnosis), and also on 
our decision as to the probability of the success or failure of 
treatment (prognosis). 

Morbid anatomy, however, regarded abstractedly as a record of 
certain alterations of structure in different parts, is of no use ; it is 
only useful as one step, and that a very small one, to the investi- 
gation of the causes of such alterations. This is the only thing 
worthy the name of pathology. The distinction, however, of pa- 
thology from mere morbid anatomy is by no means sufficiently 
impressed on us ; so little indeed, that one who collects a multitude 
of diseased products often obtains the credit of being a patholo- 
gist, when he has as little notion of the causes of disease, and 
perhaps has given as little study to the laws of nature, whence the 
diseased products result, as he has to algebra or any other science 
to which he may never have directed his attention. 

The utility of investigating morbid structures will depend on 
the mode in which you set about it. In the first place, it is 
absolutely necessary that you be familiar with the natural appear- 
ances of the various structures; otherwise you would overlook 
many things which are the result of disease, and be apt to mistake 
appearances, with which you may be unacquainted, for the effects 
of disease, which are not so. Then, in examining bodies, there is 
no great advantage to be gained, unless you know what the sym- 
ptoms were during life ; and as one case seldom allows you to 
arrive at any conclusion of general application, every dissection 
should be recorded, and the general results compared with the ex- 
perience of others, as exemplified in different collections of morbid 
anatomy, or as recorded by men of experience in this branch of 
enquiry, as the celebrated Morgagni. But the symptoms of dis- 
ease do not comprise the whole of the enquiry. The general his- 
tory of the patient, his habits, mode of life, locality, state of his ex- 
cretions and secretions, and, farther, as they were influenced by 
extraneous causes ; whether these were intentional, as medicine or 
diet, or unavoidable, as climate or moral causes ; are all material 
elements in the enquiry, in connection with the change of struc- 
ture, if we are to make it subservient to the requisitions of patho- 
logy. The actual histories attached to preparations are usually of 



11 



little real use. They will teach what is known ; but if our know- 
ledge is to progress, we must extend our investigation in the 
manner I have mentioned. Usually, when morbid structures are 
examined with more than ordinary care, it is either to discover the 
arrangement of the vessels of the diseased part (if its organization 
admit of this), to determine its chemical composition, or to com- 
pare its obvious physical qualities with those of other specimens, 
with a view to form our prognosis (supposing the part to have been 
removed by operation), as to whether the disease be likely to return, 
or whether the patient is even to recover. The latter, as one of 
the means employed to ascertain the state of the economy whence 
it originated, might be made a very useful element in preventing its 
recurrence ; but I never see it converted to such purposes. Whilst, 
as regards the other two points, namely, the arrangement of the 
vessels, or the chemical composition of the part, it is very pro- 
bable that neither the one nor the other, did we know them, would 
be of any use ; since we do not find that either has hitherto unfolded 
to us any law in the animal economy. They shew us of what life 
is capable ; they sometimes, in a negative manner, help us to a 
notion of its chemical powers ; but as to the only thing really of 
use, they leave us, as we might have anticipated, as much in the 
dark as ever. If we are ever to deduce any useful knowledge from 
investigation of morbid structures, it must be through a previous 
intelligence of those disturbances of the economy of which they are 
assuredly the product, and which, therefore, though it may probably 
also have accompanied, must certainly have preceded, the deposition 
of the morbid structure. I appeal with confidence to the experience 
of the whole profession, in proof of the entire absence of such a 
plan of investigation. I am not blind, of course, to the fact, that it is 
always difficult, and often impossible ; but the difficulty is the rule, 
the impossibility the exception ; and that the progress of pathology, 
as regards the contributions through the means afforded by morbid 
anatomy, depends on the encountering, and in some sense over- 
coming this difficulty, is, in my opinion, demonstrable. For many 
years I examined all the bodies of those who died in the Institu- 
tions with which I have been connected, where I could obtain 
permission, as well as elsewhere, whether the symptoms were 
known to me or not ; but if I place the time spent, and perhaps 
health also, against the advantages acquired, I am afraid much of 
the time might have been far better employed. The truth perhaps 
is, that, in acquiring a familiarity with the general appearances of 



12 



health and disiease, the examination of bodies is of itself, to the 
student, not altogether an useless occupation, even when you are 
somewhat advanced in the study of the profession. Still, if you are 
an industrious student, your prosecution of morbid anatomy will 
be more advantageously conducted if confined to the examination 
of cases with whose symptoms at least you have been acquainted. 
You will find life short, and every succeeding year more precious 
than the last ; and I hope to shew you, that, as surgeons, you must 
not amuse yourselves in um'avelling minute structm'e, or in col- 
lecting cabinets of curiosities. In flict, anatomy of any kind is 
only useful as litlping you to understand the natural uses or 
functions of the ^'arious parts of the body (physiology), and the 
causes of those departures from them which constitute disease 
(pathology) ; and it is requisite to remember also, that anatomy is 
only one of the means for the attainment of these ends. 

In insisting, therefore, on the importance of anatomy, both 
general and morbid. I must guard myself from misconsti'uction; 
since there are few mistakes more mischievous than the idea that 
medical science rests exclusively on an anatomical foundation. 
This idea, to which the real importance of anatomy lends consi- 
derable colouring, has, I believe, materially retarded the progress 
of our science : wherefore I shall endeavour to shew you that 
other things are requisite besides anatomy to the prosecution of 
our researches : and that, in fact, anatomy itself only becomes 
useful in helping you to the observation and interpretirlon of phe- 
nomena. I have seldom observed a person occupied in an undue 
proportion in anatomical investigations, whose reasoning was not 
cramped by it. Even Air. Hunter cannot, I think, be excepted 
from the foregoing remark ; inasmuch as many of the conclusions 
which he deduced from anatomical modes of investigation would 
rest even more securely on physiological phenomena, accessible 
by simple and direct observation of the living body. To this point, 
however, I may refer hereafter. 

If medicine held that kind of dependence on anatomy which 
it is too generally conceived to hold, there should have been 
something more of proportion observable in their progress. 
But we look in vain for such proportion. Let us compare the 
state of these sciences respectively, at some remote period, with 
their present relative condiuon. Suppose we take the rime of 
Celsus ; this is about I SCO }"ears ago : we shall find that the 
anatom}' of that day was comprised in a small compass. It 



13 



consisted chieflj' in the general knowledge of the form and ar- 
rangement of the bones, muscles, joints, brain, and other viscera*. 

I need scarcely saj that the real relations of the vessels and 
the cu'culation were unknown ; neither need 1 take much time in 
dilating on the comparative advancement of human, to saj nothing 
of comparative, anatomj, in modern times. I maj here merely 
mention the names of Haller, Hunter, Cruickshank, Zinn, ^yalther, 
Soemmering, Scarpa, Bichat, Tiedemann, Cuvier, Charles Bell, and 
I might add others equally illustrious and refer you to their works, 
to shew the immense progress which has been made in this depart- 
ment of knowledge. But I fear that if we look for a corresponding 
advance in medical science, we shall be much disappointed ; and 
farther, that in some points we shall find that we have scarcely 
advanced at all. In the first place, look at Celsus's directions for 
the preservation of health. I confess to you I know not where 
you will find any better : or consider his obser^'ations on fever ; it 
will be difficult for you to collect any, from among modern writers 
which are, on the vcliole, more judicious. 

If we take the weaker parts of Celsus, as, for example, the 
absurd variety which characterizes many of his prescriptions ; I 
apprehend we shall not have much difficulty, at the present day, 
in discovering similar ^lations of all rules, by which alone any- 
thing like a philosophical investigation of the effects of remedies 
can be conducted. 

I have mentioned the enlarged views displayed on some sub- 
jects by Celsus. It is not, however, by these alone that the state 
of medical science in his time is indicated. The symptoms of 
different diseases described by him are marked, in many intances, 
by great correctness. An example or two may be here given: 
his general views are too voluminous, of course, for quotation, 
which, since his work is so easily accessible, is moreo^^er unneces- 
sary. He gives the following as the symptoms of stone. 

" Calculosi vero his indiciis cognoscuntur : difficulter urina 
redditur paulatimque, interdum etiam sine voluntate distillat ; 
eadem arenosa est ; nonnunquam aut sanguis, aut cruentum, aut 
purulentum aliquid cum ea excernitur ; eamque quidem promp- 
tius recti, quidam resupinati, maximeque ii, qui grandes calculos 



* It is right to observe, however, that, as regards medical science, this is still 
a useful sort of knowledge, and very easily acquired; indeed, any person out of the 
profession might very easily obtain it at very little cost either of time or trouble. 



14 



habent, qnidam etiam inclinati redclunt, colemque extendendo, do- 
lorem levant: Gravitatis qnoque cujusdam in ea parte sensus est, 
atque ea ciirsu, omniqne motn, augentnr. Quidam etiam, cum tor- 
quentur, pedes inter se, subinde mutatis vicibus, implicant.'"' I had 
prepared copies of the symptoms of this complaint from different 
lectures, to show how little they varied from the above description. 
It is sufficient however to observe, that the foregoinig is a good ge- 
neral account, and includes most of the characteristics of the dis- 
order ; for even that increase of suffering which, in calculous 
patients, so frequently accompanies the ejection of the last drops 
of urine, does not occur without exception, whilst, as I have else- 
where* remarked, it attends other affections. Now, with regard to 
the general health, as affecting local diseases, Celsus seems to have 
been well informed ; and, on some points, I confess that he appears 
to me to have been rather in advance of the majority even of the 
present day. Of porrigo he says : 

" Ac neque sine aiiquo vitio corporis nascitur, neque ex toto 
inutile est. Xam bene integro corpore non exit : ubi aliquod in eo 
vitium est, non incommodum est, summam cutem potius subinde 
corrumpi, quam id quod nocet, in aliam partem, magis necessariam 
verti." 

Now all I mean to sa}', with regard to medical science at the 
time of Celsus, as compared with that of the present day, is, that, 
although in the latter some improvement may have taken place, 
yet it is very little, and certainly bears not the smallest proportion 
to that which has been effected in anatomy. 

A very capital error in anatomical investigation is seen in that ' 
regard which has been paid to all endeavours to make out the ulti- 
mate arrangement of matter — minute anatomy, in the emphatic 
sense of the term. No field can be more unprolific, since it is 
scarcely conceivable that any mechanical arrangement could imfold 
to us the laws of life, anj' more than the mechanical figure of the 
various utensils employed in a laboratory could develop to us the 
laws of chemistry. That species of anatomical investigation 
which has for its object the detection of the distribution of parti- 
cular tissues, as shewn in the General Anatomy of Bichat, is a 
very different affair ; for, if particular tissues have particular 
modes of carrying out the laws of the animal economy, it is 
obviously of great interest to identify those tissues when they are 



* Practical Treatise on the Urethra, ike. 



15 



situated in different parts of the body. It materially assists us in 
understanding, and even in predicting phenomena, in enabling us to 
refer them to some law by which they are influenced in common. 
Thus, if I know the changes produced in one part occupied by a par- 
ticular structure, say a mucous membrane, cceteris paribus I know 
what to expect in another structure of the same kind, though I 
may never, in that part, have seen any of them before. But, besides 
this, it suggests generalizations of another kind, in relation to what 
I shall have to describe when I speak of the Sympathies of the body. 
Generally speaking, the fault of anatomical investigation has been, 
that the eye has been too much employed, the intellect too little. 
In other words, the knowledge required has been sought for too 
exclusively in the physical characters of parts, rather than in their 
physiological relations, in the enlarged, and philosophical sense of 
that term ; as if, so to speak, there were no other physiology but 
that derivable from investigations of ultimate structure. 

To some departments, indeed, of Surgery, Anatomy has closer 
relations ; and accordingly we find that such departments evince a 
corresponding degree of improvement : I refer to the operative 
part of surgery*, the whole of which has been undoubtedly very 
much improved, not only by the simplification of operations already 
known, but also by the invention of others more efficient and less 
severe than those formerly employed for the accomplishment of 
the same purposes. But, even here, the improvements have arisen 
more from a philosophical consideration of obvious facts than from 
minute investigation of ultimate structure. Moreover, advancing 
surgical science has rendered operations themselves comparatively 
an inferior branch of surgery. We feel that the art of tying an 
artery, or of removing a limb, is but a poor substitute for the pre- 
vention or the cure of the disease. iVlthough operative surgery 
(from the ignorance of the public as to its real claims, from its 
actual importance in the present state of science, and from the 
high scale of remuneration justly, perhaps, allotted to it, if not as 
being a high test of skill, yet as drawing largely on our time, and 
as being productive of much anxiety) possesses a rank far above 



* In fact, more time seems to have been bestowed on endeavours to find out 
how we may safely remove diseases bj- mechanical measures, than how we should 
prevent their occurrence or remove them by aid of the powers of nature. We 
have too often, indeed, been seeking how we could most safely cut the knot, which 
it is our higher calling to endeavour to untie. 



16 



its legitimate pretensions, still the philosophical surgeon is no 
longer content to know how to remove a disease by separating it 
from the body. That enlarged cultivation of surgical science, 
which demonstrates the dependence of all local diseases on the 
state of the general frame, which in fact has rendered the purest 
surgical case a medical one also, and which has emphatically and 
for ever established, not only the connection, but the Unity, of 
surgery and medicine, has opened new fields to our ambition, and 
has taught us to aspire at the prevention of diseases which we 
are as yet unable to cure, and at the cure of those which we have 
hitherto been accustomed to remove by the knife, by the judicious 
regulation of the powers of the animal economy. But these 
objects can be achieved only by the progress of our knowledge ; 
the consideration, therefore, of the means whereby such progress 
may be effected becomes, not only a legitimate feature, but a 
principal object of a surgical discourse. 

The position of a surgeon at the present day may be thus 
illustrated : Having arrived at the discovery that local diseases, and 
indeed all local processes, depend on certain conditions of the ge- 
neral economy, he is eventually led by necessity to consider how 
he can ascertain its conditions, and how correct those which are 
disordered. This is in fact emphatically the object of the practice 
of medicine : but, instead of securing the aid he seeks, from what 
he may have been led to regard as a science, he finds that he can 
with no certainty obtain such assistance. He finds a complicated 
sort of art, which has scarcely any fixed principles ; which can 
with certainty neither predict any phenomena, nor explain the 
failure of such prediction. He finds that bleeding, calomel, 
blistering &c. are employed in one complaint ; bark, steel, and wine 
in another, opium, digitalis, squills, &c. in a third, and so on ; 
but he finds no well-ascertained laws to which the practice can 
be referred. Disposed to concede any point, that a physician can 
have the smallest pretensions to claim, he still finds that, for the 
most part, the practice of medicine consists of an art, in which 
certain effects are, in a given number of cases, produced by certain 
means, on grounds, for the most part, in the highest and best sense, 
but rational conjectures, and conducted so little in the spirit of an 
inductive philosophy, that, whether his means produce the effect 
desired, or wholly fail, he is alike unable to refer either the one or 
other to any law of nature. He feels, therefore, at once, that, if 
he is to improve his own science, and this by a knowledge of what 



17 



is called the practice of medicine; that he must endeavour to 
study it in a manner calculated to improve such a state of things ; 
since, although he may for the time avail himself of rational con- 
jectures, a man who has arrived at such a point, will never be 
content with any conjecture as a substitute for science ; which is 
satisfied with nothing less than at least a constant endeavour to 
find oat the laws by which the phenomena of the body are 
governed. 

In inducing you to consider of the mode in which you may 
best cultivate medical science, I shall endeavour, in the first place, 
to shew you that the improvements which have hitherto taken 
place therein, have resulted, for the most part, from a cautious and 
philosophical observation of obvious phenomena, and from such 
reasonings on them as were suggested by an enlarged exercise 
of common sense, or, if you will, an inductive philosophy. 

Before, however, we consider the foregoing remark, in its ap- 
plication to medical science, it may be useful to refer to some few 
of the more important discoveries which have been made in other 
sciences, the extraordinary progress of which naturally invites 
this kind of examination. For if it })e true that one science is in 
advance of another, it is obviously advantageous to that which is 
behind, to observe the means by which such advancement has 
been made. 

If we find the same instrument working with great success in 
one direction, and making but little progress in another, the defec- 
tive operation of that instrument (which is here, in fact, the mind) 
must be attributed, one would think, either to the inefficient 
manner in which it is employed, or to the stubbornness of the 
material on which it acts. Of all branches of human knowledge, 
whether we regard the sublime nature of its object, or the success 
which has attended its cultivation, Astronomy stands preeminent : 
it forms an all-surpassing monument of human intellect; and pre- 
sents, in a very striking point of view, what appears to be the 
true element of wisdom ; namely, a vast sum of Imowledge, which 
bears unchanged every kind of test that we can apply to it. It is 
interesting also, to reflect, that the demonstration which it affords 
of the power of human intellect, impresses on it, at the same 
time, the truest perception of humility. For whilst no one has 
achieved more, absolutely, than the astronomer ; no one has ar- 
rived at the same conviction of how little this is, as compared with 
that of which he is ignorant. 

c 



18 



Now it will be granted, that in the whole range of this science, 
nothing has had a more important influence, than Newton's dis- 
covery of the law of gravitation ; bj which, he was enabled to 
demonstrate, that the faUing of a body to the earth, and the 
courses and positions of the heavenly bodies, are the results of the 
same principle. It is stated, and with considerable probability, 
that the reflections which led him to this discovery, arose on his 
observing an apple fall to the ground, while sitting in his garden in 
the country. You could not imagine a fact more simple, more 
familiarly, more universally known, than such an occurrence. 
There are few things which suggest themselves to us, capable of 
being compared to it in these particulars ; yet its simplicity is not 
more remarkable than the grandeur of the result to which it led : 
and the fact that I wish you more especially to bear in mind, is, 
that as the most important discoveries often arise from the philo- 
sophical observation of apparently very simple facts ; so this dis- 
covery, of all others, as it would appear, most diflicult and most 
improbable, arose out of a fact most obvious and most simple. 

The stor^ of the apple has been doubted* ; but, so far as I can 
see, without sufficient reason : it is related on the authority of a 
friend and contemporary^, and attested by a relation^. It is true 
tliat Kepler, Bouillaud, and others, had conceived that the same 
principle influenced, in some way, the gravity of the terrestrial, 
and the motions of the celestial bodies ; and that astronomers, 
generally, were contemplating some such connection ; but this, 
instead of tending to shake the force of the direct evidence to 
which I have alluded, adds to it all the force of probability ; for, 
without preparation, it seems inconceivable that an apple falling to 
the ground could suggest such sublime deductions. But if we can 



* I perceive, in a book lately fallen into my hands, " Whewell on the History 
of the Inductive Sciences," that a view, precisely similar, as I understand it, is 
taken of the relation which the simple fact in the text bears to the discovery : but, 
lest I have not caught the author's meaning aright, I refer the reader to the second 
volume of the work in question, p. 157, et seq. Nobody, I presume, ever dreamt 
of any obvious phenomena leading to any discovery whatever, except through the 
instrumentality of that engine whose special function it is to make out the real 
relations to the laws under which they occur : but to the philosophical enquirer it 
is of the highest interest to be persuaded that, as Nature's laws are in general 
simple, so the most universal are daily exemplified in the most common, easily per- 
ceptible, and even striking phenomena. 

t Pemberton. | His niece. Voltaire's Elem. of Philosophy. 



19 



conceive a great mind previously directing its energies to the con- 
nection of gravity and the laws of gravitation generally, we may 
imagine that the apple might indeed connect that chain of reflec- 
tion, the first link of which it may still have been inadequate to 
form. When we contemplate this law in all its relations, we feel 
quite lost in its immensity. To conceive that it is so universal that 
no atom in nature is not, in all probability, under its influence ; to 
reflect that the planet we inhabit, and the countless worlds which 
surround us in space, owe their positions and regularity to the same 
principle ; that thousands and thousands of vast orbs, floating, as 
it were, in boundless space, should pursue courses of millions of 
millions of miles with a rapidity of which our external senses 
allow us to form no kind of conception ; and yet that their courses 
should, in many instances, be judged of by man ; and that they 
should be shewn to move in paths or orbits with a predicable re- 
gularity ; that even the weight of several of these stupendous 
creations should have been ascertained ; and this by man, the 
diminutive creature of another planet, thousands of miles distant 
from the nearest of the bodies in question, and probably bearing 
to many of them, little more proportion than that which a grain of 
sand bears to the globe he inhabits ; — these, and such like reflec- 
tions, so overwhelm us with wonder and amazement, as to disturb 
the calm contemplations of philosophy, and to convert the mild 
glow of an humble and grateful piety into the intemperate ardour 
of enthusiasm. 

Before, however, we leave astronomy, I should like to mention 
the following circumstances :— 1st. that its objects have, at all 
times, not only invited, but in some degree compelled observation ; 
2ndly, that no science has derived so much assistance from having 
had investigators, who were so provided for, that their whole 
minds might be devoted to the science, without being diverted by 
any necessity of applying them to the ordinary wants of life ; and, 
3rdly, that such provision was, in the earlier ages, generally rather 
the result of ignorance and superstition than of any love for 
science, was in fact the product of a belief in judicial astrology. 
You will hereafter see that the proceedings of the ignorant and 
the credulous, did we make proper use of them, might also be 
often made conducive to the advancement of medical truth*. 



* In this way, phenomena resulting from the merest quackery, may be often 
rendered conducive to the progress of truth. The nostrum vendor not unfrequeutly 

c2 



20 



You will think, no doubt, that I have said enough of gravita- 
tion for the present ; we will now, therefore, consider the origin of 
an instrument very closely bearing on astronomical science ; I 
mean the telescope* Now, here again writers do not exactly agree 
in detail ; but the main fact seems certain, that the first telescope 
was suggested to its inventor, an optician of Middleburg, in Hol- 
land, in consequence of having looked at a distant object through 
two lenses, at some distance from each other, and having been 
struck with the fact that the object became magnified. The cele- 
brated Galileo constructed a telescope about the same time ; and 
if he had heard some vague reports concerning the discovery at 
Middleburg, this seems to have been the only assistance of which 
he could have availed himself. Indeed, on this account, and from 
the circumstance that Galileo's was the more perfect instrument, 
some were led to attribute to him the honour of the discovery. 
Spectacles had been employed as far back as the beginning of the 
fourteenth century ; but there seems no question that the first 
telescope wds made by the optician at Middleburg, at the latter end 
of the sixteenth, or very early in the seventeenth century, I 
cannot here enlarge on the importance of this investigation : per- 
haps, indeed, its value cannot be properly estimated, except by the 



gives rise to circumstances, which shew the importance of operating on diflFerent 
parts by means of the sympathies which exist between them, in a manner hereafter 
to be explained. The proceedings also of the homceopathist have a tendency to 
open another channel, by which the public may perceive what we often in vain 
endeavour to demonstrate to them — viz. that cautious living will do a great deal, 
without any medicine at all ; and that, without this, medicine is frequently of no 
avail whatever — nay, that it may readily exasperate the evils which it is its ob- 
ject to remove. But, at present, this last species of quackery is too much in vogue 
perhaps for the still voice of reason to be heard amidst the clamours of credulity. 
By and by, however, patients may be induced to relinquish their infinitesimal 
doses of medicine, whilst the care of their habits is continued ; and this will pro- 
bably help to enligthen them. But the truth, howe-ver humiliating, cannot be 
concealed, that there is scarcely any assertion so absurd, but that we find it diffi- 
cult, and, as regards the public, impossible to disprove it. Practically, this is a 
severe, but just retribution, on those who would make science a mystery, whilst it 
powerfully impresses the low condition of the science. The remedy is, to improve 
the science, and to disseminate a knowledge of its elementary principles. This is 
the only plan by which common sense can really be opposed to ignorance and 
credulity. 

* The endeavours which some have made to trace the telescope to Roger 
Bacon, Baptista Porta, and others, are regarded by writers on this subject to have 
failed. 

The first reflecting telescope was invented by Sir Isaac Newton. 



21 



astronomer. I may, however, mention that its first fruits were no 
less important than the discovery of the satellites of Jupiter by 
Galileo. Here you have another discovery, exercising the most 
powerful influence on the progress of the most perfect of the 
sciences, arising out of the observation of a very plain and obvious 
phenomenon. I might, indeed, also have observed, that spectacles 
are said to have been first made in consequence of a similar cir- 
cumstance. It may be well, before quitting the subject of the 
telescope, to remark that one of its most important improve- 
ments, namely, the rendering it achromatic, was made from 
considering the obvious structure of the eye by Mr. Dollond*. 
Even those discoveries which have been made from less obvious 
or less frequent phenomena, have generally been found to exhibit 
some striking exemplifications on the surface (if I may so speak) 
of Nature. The rainbow, as an illustration of the composite na- 
ture of light, is a glaring instance of this kind. I have here 
adduced, in support of my position, one or two instances of the 
most striking character, because, while they all relate to a science 
which is the most advanced, the case of gravitation in particular 
affects the w^hole circle of human knowledge. Other branches of 
science, however, -afford examples of a similar description. In 
reflecting on the botanical system of Linnaeus, imperfect though it 
may be, it is impossible not to feel great pleasure in observing so 
many interesting results obtained by the observation and compari- 
son of such obvious phenomena. What is there more attractive in 
a plant than its flower ? From regarding any number of flowers, 
even at a distance, we derive sensations of cheerfulness and delight ; 
and, when we are close enough to examine them, we perceive, 
in the diversified manner in which their stamina and pistils are 
disposed, in the beautiful and varied arrangement of their colours, 
in the delicate pencillings by which they are adorned, and in the 
delightful fragrance which many of them exhale, so many cir- 
cumstances facilitating, inviting, and even, as it were, commanding 
our observation. All this is true, when spoken in relation to the 
exercise of the naked eye ; but, if w^e extend the range of vision 
by a magnifier, of even moderate power, these inducements to 
attention become indefinitely multiplied. Now, on the difi"erences 



* Euler, however, had inferred the possibility of a combination of lenses 
which would not colour the object, from the human eye, where it is evidently ac- 
complished. — Whewell's Hist, of the Sciences, p. 362, 



22 



on the number of the stamina and pistils, and their relations to 
each other, and to some other parts — not so obvious, indeed, but 
to the examination of which they appear almost necessarily to 
lead — the Linnaean arrangement is founded. Even the natural 
classification of Jussieu, though more perfect and comprehensive, 
and requiring more labour, yet primarily depends on the investi- 
gation of structures, not always, perhaps, equally striking, but still 
easy of observation. The strong conviction which I entertain of 
the utility of insisting, thus at the beginning, on the importance 
of the observation of common phenomena, may perhaps render 
me tedious ; but T cannot quit the subject without noticing one or 
two points which, if they have not a more important, have perhaps 
a more interesting bearing on medical science. 

A circumstance of no less common occurrence than a pump 
getting out of order, led to the discovery of atmospheric pressure. 
The water of a pump having fallen below its usual level, Galileo 
sent for a pump-maker to repair it. The pump- maker, however, 
could find nothing wrong in the pump ; but said that the water 
would not suffer itself to rise above a certain height. Galileo is said 
to have attributed this to the attraction of the piston ; which, when 
the water had reached about thirty -four feet, was overcome by the 
gravity of that length of column. Torricelli, his pupil, was the 
discoverer of the true explanation of the phenomenon, namely, 
the pressure of the atmosphere. Of course, he tested this by 
experiment; for, if atmospheric pressure would raise a given 
column of water to a given height, it would necessarily raise any 
other fluid in a degree proportionate to its gravity. This he 
proved with regard to mercury ; and thus the fact was established*. 
I believe it will be found that no branch of science, of the history 
of which we have any accurate account, fails to furnish illustra- 
tions of the proposition which I am endeavouring to impress on 
you. Electricity, in its relations to every thing around us, is a 
subject of all-absorbing interest ; and, since we have been taught 
to identify it with galvanism and magnetism, and to view it in 
connection with its bearings on the chemistry of Nature, has 
opened fields to the philosopher; the cultivation of which has 



* About the year 1640. Amongst other important results of this discovery, 
the barometer was its direct product, and the influence which atmospheric pressure 
has on boiling points of liquids, and various other phenomena — in fact, the science 
of pneumatics. 



23 



already produced the most valuable fruit, and which promises a 
yet more abundant harvest in the discovery of principles and re- 
lations in Nature, at present beyond all idea or calculation. Among 
the most distinguished of those to whom science is thus indebted, 
it is an agreeable thing to find men, the arena of whose labours has 
been the Royal Institution of our own country. Now, if we trace 
back this science, we shall find that the ancients knew very little 
about it : that it is one of modern origin ; and that as early a step 
in its progress as we can discover, worth mentioning, was made in 
1600 ; when a treatise on the subject was published by Gilbert, in 
this country ; that, in fact, nothing material took place till the dis- 
covery of galvanism, by the man after whom it is named ; namely, 
Galvani. Now, the discovery of galvanism, important as it may 
be, was the result of a very striking fact ; and that fact itself, in 
the case in question, was accidental. It has been well observed, 
however, that " discoveries, apparently the result of accident, 
always, on closer examination, imply the exercise of profound 
thought." This is, indeed, true, and it would be unreasonable 
to suppose it to be otherwise, or that the laws of Nature should in 
any case be intelligible without a proper use of the instrument by 
which alone they become so — that is, the mind*. But still the 

* Long after I had written this discourse, I was much pleased in reading the 
follov/ing ptissage in Mr. Whewell's work on the History of the Inductive 
Sciences : — " It has been well said, that true knowledge is the interpretation of 
Nature, and that it requires both the interpreting mind and Nature for its object — 
both the document, and the ingenuity to read it aright — thus, invention, acuteness, 
and connection of thought, are necessary on the one hand, for the progress of philo- 
sophical knowledge, and, on the other hand, the precise and steady application of 
these faculties to facts well known and already conceived. It is easy to point out 
instances in which science has failed to advance in consequence of the absence of 
one or other of these requisites : indeed, by far the greater part of the course of 
the world exhibits a condition thus stationary with respect to knowledge. The 
facts, the impressions on the senses, on which the first attempts at physical know- 
ledge proceeded, were as well known long before the time when they were first 
turned to account, as at that period. The motions of the stars and the effects of 
weight were familiar to man before the rise of the Greek astronomy and me- 
mechanics ; but the " Di\dner mind" was still absent. The art of thought had 
not been exerted, by which these facts were bound together under the form of 
laws and principles; and, even at this day, the tribes of uncivilized and habt'- 
civilized man, over the whole face of the earth, have before their eyes a vast body 
of facts of exactly the same nature as those with which modern Science has built 
the stately fabric of her physical philosophy ; but, in almost every other part of 
the earth, the process of the intellect, by which these facts become science, is un- 
known. The scientific faculty does not work, — the scattered stones are still there, 



24 



fact, on wliich the mind's power is exercised, is generally simple, 
and requires nothing but the most ordinary capacity for its per- 
ception. Its relation to the law which it illustrates, is another 
affair, as was the case in the example before us. Galvani's* wife, 
being indisposed, had been ordered to take frogs by way of diet ; and 
one of them lay on a table near an electrical machine, which was 
in action. A pupil of Galvani's happened to touch a nerve of the 
frog's leg with the point of a knife, when instantly the limb was 
thrown into convulsions. This occurrence, which was mentioned 
to Galvani by his wife, — for it appears that he was not even present 
when it took place, — excited him to an investigation, which he im- 
mediately prosecuted with ardour. I cannot go farther into this 
part of the history of electricity, than to say that the result of the 
enquiry, being further developed by the reasonings and experi- 
ments of Volta, led to the invention of the battery which bears 
his name. Indeed, galvanism is thus often called Voltaic Elec- 
tricity. I shall be obliged to refer again to this subject; but its 
importance may be gathered from the fact, that it was by the 
agency of the Voltaic pile or battery that Sir Humphry Davy first 
shewed the influence of electricity on chemical affinity ; and that 
we have been led to the knowledge of the fact, that all chemical 
actions are, indeed, electrical phenomena. When we consider the 
changes in our \'iews resulting from this conclusion, and venture 
to glance at the consequences to which it may yet lead, we scarcely 
believe it possible, any more than with regard to the discovery of 
gravitation, that effects so stupendous, can have arisen from such 
small beginnings. 

Examples of a similar kind might be indefinitely multiplied ; 
but it is now time to look a little homewards, and apply our en- 
quiries to matters more directly connected with nciedical science. 
We sliciU not fail to find plenty of facts for the purpose ; and, for 
my own part, I should think, were every one of them stated, that 
the requisite space would be well occupied ; but, as you may pro- 
bably be of a different opinion, I shall here select one or two only 
of the most striking, as sufficient. Let us, in the first place, con- 
sider Harvey's discovery of the circulation of the blood. We 



but the builder's band is wanting : — and, again, we have no lack of proof that the 
mere ac tin :y of thought is equally inefficient in producing real knowledge." — 
AVhewell's Hi.-r. of ^led. Sciences, vol. i, p. 77S. 

* Galvani was Professor of Anatomy at Bologna, 1760. 



25 



shall derive much instruction from the consideration of this sub- 
ject, and find that it places, in a striking point of view, the 
superior utility of the careful examination of obvious phenomena, 
as contrasted with that minute search into intimate structure, to 
which anatomists appear to be so partial. The discovery of the 
circulation arose out of the contemplation, not only of a very 
obvious fact, but of one which had become well known ; namely, 
that the superficial veins were furnished with valves, and that the 
heart was provided with a similar mechanism. Now, a consider- 
able time before this, these valves had been observed by Father 
Paul and Sylvius* ; and besides^ the passage of the blood through 
the lungs had been pointed out by Michael Servetus ; and even 
the valves of the heart had been described by Realdus Columbusf. 

Various conjectures concerning the circulation of the blood 
had been made in ancient times, but nothing that even approached 
the truth, until nearly the time of Harvey, when the observations 
of the two authors whom I have just mentioned, to which may be 
added those of Andreas Csesalpinusij:, bore so closely on the truth, 
that we cannot help wondering that neither of them discovered it. 
Michael Servetus had certainly correct ideas as to the transmission 
of the blood through the lungs ; whence, he says, it passes to all 
parts of the body. He was a Spaniard by birth, being born, in 
1509, at Villanova, in Arragon. Unfortunately, he became a 
theological disputant, and, ultimately, a victim of religious fanati- 
cism. He was burnt at the stake, at Geneva, in 1553, consequently 
at the age of forty-four. Realdus Columbus gives a very clear 
description of the valves of the heart, and of the transmission of 
the blood from the right side, through the lungs, to the left ; and 
thence, through the aorta, to all parts of the body. x\ndreas 
Csesalpinus, who wrote immediately after Columbus, remarks, 
amongst other things, that if a ligature be put round a vein, the 
vessel swells on the side remote from the heart. Now, Fabricius 
ab Aquapendente, although he did not discover, appears to have 
been the first person who particularly described the valves of the 
veins, of which he had been told by Father Paul ; and the cele- 
brated Harvey was one of Fabricius' s pupils. I mention these 
things merely to shew that the discovery of Harvey was, after 
all, a clear and simple deduction from facts which were pre- 
viously known, and, indeed, of obvious character. The discovery 



* About the end of the 16th century. t 1559. % Born at Arezo, in Italy. 



26 



of parts so palpable as the v^alves of the heart, or even of the \-eius, 
hy men in the constant habit of anatomical pursuits, cannot be 
regarded as matter of much wonder. Thev were not only objects 
of sight, but such as required no painful or industrious exercise of 
it : the application, however, of the fact of their existence, was an 
intellectual process, and was Harvey's discovery. And although, 
as with regard to many other discoveries, we now wonder that the 
inferences drawn by Harvey were not perceived before : the very 
cii'cumstance of their having escaped previous obsers^ers, may 
enable us to appreciate the order of mind which did at length de- 
duce them. I need not go into the investigations of Har^-ey on 
this subject; my object is, merely to shew you the facts on which 
they were founded. In comparison with such a discovery, how 
insignificant do the labours of those anatomists appear, who have 
distinguished themselves by minute or microscopal observations, 
as Ruysch, Malphighi, or Lewenhoeck !* 

In selecting instances from surgery, which shall most happily 
combine simplicity in the ^dews whence the improvement origin- 
ated, with importance in the result ; I cannot do better than cite the 
operation for aneurism, first carried into practice by John Hunter ; 
i^ecause, whilst an impro-\dng science bids fair to circumscribe, 
within very narrow limits, this (I mean the operative) part of 
surgery, the causes of aneurism render it extremely improbable 
that the occurrence of that serious malady will be materially di- 
minishedf. To understand this fully, you should know that aneu- 
rism, which consists in the enlargement of an artery, or, more 
commonly, in the giving way of its internal coat, is seldom the result 



* As contrasting the two methods of observation, viz. that of obvious facts, 
whether of structure or function, mth minute investigation of structural arrange- 
ment, the application to our professional researches of the following observation 
of Lord Bacon is well worth our consideration: — " Nor is it a less misfortune that 
men, in their philosophic contemplations, bestow their time in discovering and 
treating the ultimate principles, or last resorts of Nature, whereas all utility or 
power of acting lies in the midway : but, in general, men cease not to abstract 
Nature until they arrive at potential and uninformed matter ; or, until they di-^ide 
her so far as to come to atoms : which things, though ever so real, make but little 
to the advantage of mankind." 

t I do not multiply examples of this kind, drawn from professional sources, for 
two reasons : first, because it is very easy to lose sight of the argument in a super- 
abundance of illustrations ; secondly, because they will be described in their 
proper places, and in future parts of the work refresh the memory and induce a 
sustained impression of that which I am desirous of conveying iu these discourses. 



27 



of any single cause ; or, if it be, the cause is one of such a nature 
as not to be perceptible, in time, to afford us any chance of its pre- 
vention. An artery may thus give way as a direct consequence 
of the force with which the heart impels the blood into it, or from 
progressing disease of its coats, rendering it at length unequal to 
the ordinary momentum of the circulation ; or, occasionally, from 
sudden extension in violent motions of the body, or from being 
unfavourably circumstanced as to position ; such as one which, 
from the occupations of the individual, may keep it almost ha- 
bitually in a state of curvature, in which the force of the circula- 
tion, instead of acting in the direction of the axis of the vessel, is 
exerted against its sides, as in those who ride much, as post-boys, 
&c. Either of these causes may act separately ; but, usually, they 
are more or less combined. 

The old operation, which consisted in cutting into the aneu- 
rismal tumour, turning out the blood, and tying the vessels above 
and below, was not only extremely severe, but very generally, in- 
deed, fatal. Now, experience had shewn the following facts, — 
that, in some cases^ the retardation of the current of blood through 
the aneurismal sac had produced the cure of aneurism ; and, 
further, that in tying the artery close to the aneurism, it was fre- 
quently found to be diseased. It was a very obvious inference 
from such facts, that if a ligature were placed on the artery at a 
reasonable distance from the disease, it would be more likely to be 
placed around a sound portion, whilst it would very much retard, 
if not entirely impede, the course of the blood through the cavity of 
the aneurism. Mr. Hunter, acting on these considerations, tied 
the femoral artery for an aneurism in the ham : the proceeding was 
entirely successful, and now forms, perhaps, one of the simplest 
and best of our operations. Few operations take less time, few 
are attended with less suffering, and of those comparable with it in 
importance, none are more generally successful. 

But, as I presume enough has been said on this topic, I will 
now come to the last instance ; and which, in my opinion, as re- 
gards professional considerations, is the most important of all, — 
the institution of that improved surgery which has raised an art 
of, comparatively speaking, very mean pretensions, into a science, 
— the surgery which teaches that the diseases of parts of the 
body are but phenomena manifesting the condition of the 
whole — the exposition of the " Constitutional origin and treat- 
ment of local diseases," by Mr. Abernethy. The whole pheno- 



28 



mena bj which the relation between local diseases and the 
general health is established, are of the most common and 
simple description. Thej are within the range of everj compre- 
hension, and many of them are familiar to the most ignorant. 
The more we consider the facts, the more are we struck with their 
number, their glaring nature, and the luminous manner in whichu 
the J point to the conclusion. 

It would not be correct to state, that general views of the con- 
nection of the general health with local affections, had not been 
occasionally entertained long before. Celsus appears to me to 
have had exceedingly good general noiions on this subject ; and the 
quotation which I have given from him with regard to porrigo, 
shews that he even possessed something more. Neither is it by 
an}' means uncommon to find old surgical writers summing up a 
catalogue of remedies, by saying that if these are unsuccessful, then 
some physician should be consulted, as " the blood is in an impure 
state," or some ecjuivalent expression. But if we can thus trace 
a faint recognition of the connection of local diseases with the 
general health, it is all we can do. ^Ye never find it brought to 
bear, with any perception of its real importance, on the treatment 
of diseases. ^Yhatever appreciation it has obtained, appears to 
have been more amongst persons who belonged rather to the public 
than the profession. Mr. Abernethj' was the first person to bring 
the vast multitude of facts to bear on the practice of surgery. 

The philosophical character of Mr. Hunter's labours would, no 
doubt, make a sensible impression on a mind like x\bernethy's ; on 
which, also, the laborious discourses which he is said to have deli- 
vered on the sympathies of the body (with the sole effect of proving, 
as Mr. x\bernethy himself said, that the whole body sympathized 
with all its parts), would not probably be lost. Indeed, Mr. Aber- 
nethy very soon applied this fact, and various others, to their 
proper uses ; and, in carrying into practice the principle to which 
they led, may be said to have revolutionized the practice of sur- 
gery. A comparison of the state of surgical science at the time 
wliich preceded him and the present, would be the true mode of 
estimating our debt to Mr. Abernethy : nor are our learned 
brethren, the physicians, wholly exempt from obligation to him. 
When Mr. Abernethy first broached his notions, people, very 
charitably, no doubt, said he was mad. I do not believe that they 
meant that he was insane, but that his notions were wild, visionary, 
and so on. 



29 



Now things are changed. We now neither doubt of the truth 
or importance of the connection between the general health and 
local diseases, nor between these and the digestive functions, to 
Vv^hich Mr. i\bernethj was erroneously thought to limit his views*. 
We now only differ in degree ; we are divided as to the extent to 
which attention to the health in general, and the digestive organs 
in particular, should be carried ; as if the admission of an influ- 
ence exerted on every disease did not, as a matter of common 
sense, absolutely command the most refined, unwearied, and philo- 
sophical investigation of it in our power. You will have opportu- 
nities of judging how this investigation has been conducted, and of 
the extent to which it has been characterized by the principles of 
inductive reasoning ; you will then be surprised rather at the pro- 
gress which medical surgery has made, than that it should not 
have advanced more rapidly. 

To return to Mr. Abernethy. His facts are not only not ab- 
struse, obscure, or difficult to perceive, but they are of the most 
trite and ordinary description, not only such as must have been 
known to every professional man, but to most of the public also. 
These facts, and a multitude of others, not only estabhshing Mr. 
Abernethy's views, but also enlarging and improving their applica- 
tion in practice, it will be my business to bring forward hereafter. 
Here I only say so much as may serve to convince you that it is 
vastly more important that you should observe well, and carefully 
reflect on obvious phenomena, than that you should be intent on 
the discovery of those which are new, much less such as are to be 
sought for, only in minute arrangements of structure. 

Having said thus much on the advantages derivable from the 
observation of common or frequent phenomena, I would endea- 
vour, in the next place, to give you a few simple rules for the mode 
of conducting your observations. 

Now, as a preliminary step, I wish to establish in your minds 
the conviction that (as Lord Bacon expresses it) Nature " has a 
meaning in everything she does :" in other words, that there is no 
occurrence, however common, which is not the exemplification of 
some law of Nature. As the operation of one law is usually found 



* If it were said that Mr. Abernethy limited his practice to attention to the 
digestive organs, it would, as applied to his Medical Surgery, be much nearer the 
truth ; but to say that his niexos of the causation of diseases were restricted to the 
influence of the digestive organs, is neither true nor just to his memory. 



to aocomplish an iiifinity of ends, so the discovery of any one exem- 
plification of it usually leads to tlie explanation of many other 
things of which we were previously ignorant. Attention to the 
habits of animals strongly suggests to us the constant operation of 
laws, whilst it furnishes numerous examples of the objects which 
they accomplish. When we see birds in rapid flight, soaring in - 
the air or coursing backwards and forwards over fields, meadows, 
and streams ; or the numerous insects w^hich flutter about us on a 
summer's morning, or which, in such varied forms and with such 
different velocities, run across our path ; w^e are apt to take but little 
notice of either. But the case is very different when we consider 
that what at first had the semblance of sport, play, or accident, is, 
in fact, the exemplification of various instincts — that the birds are 
either flying long distances in search of food, or returning home after- 
wards, as happens with the rook or pigeon, watching their prey or in 
chase of it, as the hawk, or carrying food for their young, or materials 
for their nests — that insects too have their objects; that the flight of 
the butterfly, apparently so irregular, is nevertheless unerring ; that 
she not only seeks her own food, but lays her eggs, in many cases, on 
a place where there would be no food for her young, did it not 
happen, in many instances, that they feed on articles which the 
parent never touches. Insects which are seen running across our 
path generally afford information, if we watch their movements. 
They either inform us of their domicile, the nature of their food, or 
some other circumstance equally interesting. I once vv^atched an 
ant, near the sea shore, carrying, as that insect is well known to do, 
a weight considerably greater than herself Her way was to the 
last degree rugged, and, as regarded her size, one would say moun- 
tainous, as she had large masses of smooth stone and rough chalk 
to ascend and descend, in every possible variety of inclination. 
Nothing could be more interesting than her modes of operation ; 
and most of them were perceptibly in accordance with some well- 
known scientific principle. But is it possible not to feel interest in 
the sublime truth arising out of such simple phenomena? You 
need not be in the country to observe animals. The domestic cat 
and the house fly are exceedingly interesting. How beautiful is it 
to see, in the prehensile playfulness of the kitten, the education ne- 
cessary to her becoming the successful mouser, or to watch the 
common house fly, either in his walks with his air-pump feet upon 
the ceiling, or in his rapid and angular flight, which would seem to 
indicate, that, a prey himself, he is also predacious ; and may be 



3J 



pursuing, aided by his complex eye, objects to us invisible. Not a 
vapour that arises fi'om the earth, not a drop of rain that falls on it, 
not the slightest breeze that blows, neither the rest nor motion 
of a particle of dust, neither the heats of summer, the cold of 
winter, nor the genial warmth of spring or autumn, occur but in 
obedience to certain laws. In our own persons, we may be assured 
that, whether we walk, stand, sit, eat, drink, feel ill or well, 
happy or miserable, think, compare, judge, feel, hear, or see, or in 
fact do anything, — we may be assured that the powers through 
which we do it are regulated by laws ; and that, although one law 
always explains a variety of phenomena, yet that one act will fre- 
quently have reference to more than one law. In short, whether 
we regard the skies above us, the earth beneath, the atmosphere 
around it, the w^aters on its surface, or that which is beneath it, we 
never fail to see everywhere something of the highest interest. 
Every law of nature is a problem ; every phenomenon may be re- 
garded, not merely as its product, but as a key to its solution : and 
it is through a multiplied solution of such problems that Philo- 
sophy can alone establish her high calling, her true position, which 
shall demonstrate that Religion and Philosophy lead to where Wis- 
dom and Piety meet in a common conclusion. 



Now to whatever of the phenomena of nature our observations 
be directed, the result will entirely depend on our mode of conduct- 
ing them. I could not give you full instructions on this point 
unless I were to write a kind of Novum Organon, which is not 
compatible with the accomplishment of the several other objects 
of this work*. I would advise every one, however, to study Lord 
Bacon. His Novum Organon cannot be read too often, nor studied 
too much ; for, while what he inculcates is, as it appears to me, 
nothing more than the patient and unbiassed exercise of common 
sense, still he teaches an enlarged exercise of it, accompanied by 
so acute a circumspection as to be by no means so easy as you 
might be disposed to imagine. I shall, however, endeavour to 
give you a few simple rules, which may not be without their use 
to you in conducting your observations. 

In considering a fact, it is of the utmost importance that the 



* See Preface. 



32 



mind should be unbiassed by any preconceived notions. These 
constitute what Lord Bacon treats of under the term Idols in his 
Novum Organon, though perhaps the greater part of our prejudices 
may be resolved into the influence of authority. If we examine 
our minds with great severity, we shall find that there are few sub- 
jects on which we have not some notion or other, without being - 
able to answer the question. From what facts do I deduce such an 
opinion ? Many erroneous notions are frequently the result of edu- 
cation ; they are imbibed very early, and often become indelible ; 
as Sir Thomas Brown very justly says, in a quotation from 
Lactantius, "Primus sapientiae gradus est, falsa intelligere." Lord 
Bacon expresses the state of mind adapted for scientific investiga- 
tion very happily, when he says, " The kingdom of man founded 
in the sciences can scarce be entered otherwise than the kingdom of 
God ; that is, in the condition of little children." Nothing should 
be admitted into the consideration that is not as well ascertained 
as the fact we are supposed to be considering. Now", freedom from 
prejudices is very easily seen to be necessary to correct thinking ; but 
it is by no means so easily obtained. The first difficulty in our way 
arises from authority, which exercises such extensive influence on the 
formation of opinions, that, where one man thinks for himself, 
thousands bow to authority; in fact, allow others to think for them. 
Hence the error of one man becomes the error of thousands. In 
the case of Aristotle, it became the error of millions. No man 
broached more absurdities than he : no one ever possessed the 
same kind of influence over the minds of men. His authority ac- 
tually kept science from progressing for ages ; and the persecution 
of Galileo, which was, so to speak, but an occurrence of yesterday, 
although it emanated directly from the Church, was, in its origin, 
due to the errors of iVristotle*. In fact, as regards Authority in 
general, the whole history of human knowledge strikingly illus- 
trates the truth and importance of the following reflection : — that 
there never was a proposition so absurd, or a theory so untenable, 
but that it met with some supporters ; nor any truth, however sim- 
ple, luminous, or useful, wliich had not, at its first discovery, to 
encounter opposition. 



* I am not insensible of the successful powers of generalization displayed by 
Aristotle ; nor do I mean to refer the long reign of error entirely to the influence 
of his authority ; but still there is no single instance, which illustrates the proposi- 
tion, comparable to that of which this philosopher is the example. 



33 



The influence of Authority originates from many causes, the 
nature of which is exceedingly different; some of the more ob- 
vious may be briefly mentioned. From our cradle we are accus- 
tomed to the recognition of Authority in the necessary gui- 
dance which we receive from our parents in forming our notions 
of right and wrong ; and habit induces us unconsciously to extend 
that which we have found right and safe in questions of a moral 
kind, by an easy transition, to matters of a diiferent nature ; 
questions involving a vast variety of dissimilar phenomena, ques- 
tions on which we are assisted by no direct revelation, as in morals, 
but which, depending for their solution on the observation of laws 
only, require perception, reflection, comparison, judgment, in short 
the highest exercise of our reason. 

Again, in the study of every science, the elementary parts are 
generally interesting. Charmed on the very threshhold of our 
studies, we are apt to over-rate the knowledge of our teacher (and 
in the confidence engendered primarily by necessity and secondarily 
by a certain number of facts which are demonstrable), to give cre- 
dence to the opinions which may accompany them. But mark the 
result. Not one man in fifty arrives at what is called the comple- 
tion of his education without feeling that he has many things to 
unlearn. 

But were reliance on scientific authority always to result from 
so good a disposition as that which would found it on the tried ex- 
perience of its moral excellence, or on the amiable confidence with 
which a pupil looks to his master, we might indeed excuse, however 
much we might still regret, its injurious influence on science. But 
the spring, the real source of reliance on authority, is neither so 
amiable nor so easily observed. On the contrary, it is deep and 
selfish: it finds an equivalent for the confidence bestowed in the 
blind indulgence of indolence, or in the gratification of some other 
equally selfish feeling. A reliance on the dicta of others is easy ; 
familiarity with the accumulated labours of our predecessors is ac- 
quired without any other exertion than the careful perusal of books 
for the most part interesting. iV vast quantity of intellectual fruit, 
called learning, is thus easily obtained, and brings w^ith it a present 
fruition in the respect awarded to it by mankind, who seldom stop 
to discriminate between learning and knowledge. Contrasted with 
this, the investigation of Nature appears at first laborious ; the 
record of facts, so long as their relation to the laws which they 
exemplify remains undiscovered, is a kind of drudgery at w^hich the 

D 



34 



mind is apt to revolt ; and, although when the discovery is at last 
made, nothing can exceed the delightful elevation of the mind at 
viewing so vast a number of secrets unlocked at once, still, as the 
fruit is precious, so cannot it be acquired without exertion. Con- 
stant thinking is necessary. This kind of intellectual digestion is 
the only means by which the mind converts learning into knowledge. 
Facts are its food ; the determination of their mutual relations, and 
the laws whence they emanate, constitutes its digestion. More 
learned men may have been useful compilers, but have seldom ex- 
tended the bounds of knowledge. Accurate observers of Nature 
have seldom failed to do so. Nor does the admission of the greater 
power, resulting from learning and acute observation when com- 
bined, militate against the superiority of the latter considered 
singly. 

But, whilst I would caution you against the undue influence of 
authority, I would guard you, on the other hand, from its indiscrimi- 
nate rejection. Successful observers of Nature deserve our utmost 
study and attention ; the most trivial circumstances regarding the 
education and conduct of their minds are to be considered with 
interest. Most men are capable of perceiving the value and im- 
portance, nay, of being surprised by the simplicity of relations 
which they would have been unable to discover. The real lover 
of truth will also study the proceedings of successful observers, 
with the probable advantage of discovering how they avoided 
various misdirecting influences by which our slowly progressing 
moral powers shackle or impede our intellectual faculties, I 
have above adverted to selfishness as one of the sources of our 
reliance on authority ; and I need scarcely observe how often our 
reasoning powers are clogged by the dominant passion. Many 
men persuade themselves that they are searching for truth, when 
they are contending for victory ; or when they are favoring their 
love of ease by hastening to a conclusion which they are not indus- 
trious enough to work their way to from safe and legitimate pre- 
mises. Others persuade themselves that the relations of a fact must 
be so and so, not from a sincere conviction of the truth of their 
views, but because they support some favorite theory. In this way, 
success itself is apt to mislead a man ; for when he has made out 
some true relations among phenomena, pride usurps the place of 
humility, and caution is laid aside in his haste to apply the law 
which he has discovered to phenomena which it does not explain : 
but facts well attested, whencesoever derived, are to ha recorded. 



Circumstances are often accidentally developed to men who are no 
great observers of nature ; and if a fact be recorded without its true 
explanation, it is better that it be stated without any ; as it thus 
becomes so far a more sure basis for reasoning, inasmuch as it is 
then less likeljto be coloured inanjwaj by the views of the writer. 
In this way, the observations of the most ignorant are often of great 
use. However, you will seldom find facts thus isolated ; they are 
generally accompanied by some conclusion : and we have not only 
to consider the author's facts, but also whether they justify the con- 
clusion he deduces from them. This leads us to determine what 
those relations are, which should exist between facts and the con- 
clusion which we deduce from them. The fact should fully and 
satisfactorily account for the conclusion. It is not sufficient that 
there be nothing irreconcileable or contradictory between them; 
but their mutual relation should be one which the fact can be per- 
ceived to bear to no other conclusion, and the conclusion to no 
other fact whatever. Generally, any conclusion, or any explana- 
tion of a fact which involves much complexity, should be received 
with suspicion ; because every truth we discover has no feature 
more striking than its simplicity. Any thing also which involves 
an exception to an apparently established rule, should be received 
with the same caution ; true exceptions being so rare, that the ex- 
istence of any may reasonably be doubted. Even the very remark- 
able exception which water seems to form to the general law of 
contraction on the subtraction of its heat, is attended by some dif- 
ficulty. For although, at the freezing point, it occupies more space 
than when some degrees above it, yet at about forty degrees it ob- 
serves the same law as other forms of matter. Therefore, as the 
laws of crystallization seem to give definite forms to the molecules 
of crystallizing bodies, it is quite conceivable that the molecules of 
ice may be so formed as really to forbid that closeness of adaptation 
which takes place in a fluid state. When the important results of 
ice being specifically lighter than water are considered, this view is 
far from improbable ; and it would show that the expansion of ice 
was not in consequence of cold, but of some change in the arrange- 
ment of its molecules, causing them to occupy more space. A 
conclusion, to be the basis of any further reasoning, should be 
tested by repeated observation and experiment. Probability may 
exist on grounds less strict and determinate ; conviction should rest 
on no other. A conclusion may be probable which naturally 
explains the facts ; but still it is but probable. The two theories of. 



36 



light, for example, explain, perhaps with tolerably equal success, the 
phenomena ; but this very circumstance is a bar to our arriving at 
any conclusion as to the truth of either. Indeed, were we at all 
driven to a conclusion where two theories explain the phenomena 
equally w^ell, the safer one w^ould be, perhaps, that both of them are 
wrong. 

To establish between facts and inferences the close relation 
wliich I have endeavoured to describe, is the great object of in- 
ductive philosophy : and, although the rules are of difficult ob- 
servance in medical science, and not ahvays easily to be followed 
in any ; yet, in no science more than the medical, is it necessary 
to strive at the greatest possible approximation to them. In most 
other sciences, chemistry, for example, the phenomena refer to 
objects which, although they exhibit various changes in their 
relations to other existences, and in their own forms, can yet be 
placed under circumstances so identical, as to be made to observe 
determinate modes of action. Thus, if I wish to act on a piece of 
metal, any number of times, T can take it of the same weight, the 
same size ; I can place it in the same temperature, in the same 
vessel ; I can ascertain that it is of the same density, and influenced 
by the surrounding atmosphere in the same manner ; or I can place 
it in vacuo ; so that I have the strongest possible assurance that any 
new phenomenon results solely from the agent I myself apply to 
it ; and thus I can ask of Nature the question intended, so as to 
limit its signification, and thus assure myself that my enquir}' is 
the same, and that I have not made it under circumstances of a dif- 
ferent nature, on different occasions. But in animals, and (from the 
superaddition of moral influences) "especially in man, we have not 
the same opportunity of assuring ourselves that we have observed 
phenomena in any two cases imder precisely the same circum- 
stances. Original peculiarity of constitution, differences acquired 
from habit, age, or disease, the varjing conditions of various 
organs, and the inscrutable operation of complicated moral causes, 
lead to such endless varieties in the condition of the nervous sys- 
tem, and constitute so many elements of change, which are un- 
appreciable, that we can never be certain of placing the same 
person, twice following, under circumstances exactly similar. No 
w^onder, then, that w^ e cannot as easily arrive at conclusions by 
strict induction, as they can who pursue other sciences : but it is 
to be feared that the task, when its difficulty should have given 
rise to a corresponding increase of exertion, has been too often 



37 



rejected as hopeless; and tlmt, because we could not ar me at con- 
clusions which were certain, we have not sufficiently striven at such 
approximations thereto as are really within our grasp. 

Further, it is demonstrable, that we have often rendered what 
was already difficult, impossible, by the mode in which the inves- 
tigation has been conducted : neither need I say how often reason- 
ing has been laid aside, and replaced by an avowed empiricism. 
Now, I do contend, that medical science can never progress unless 
we set to work in a different manner. I further contend, that the 
present mode of observation may be materially improved, as I 
hope to shew you in due time. Perhaps it will be more useful to 
spread, what I have to offer on tliis head, over the subjects to 
which it especially refers, than to go at length into it at present : 
still, as the subject is important, I may here illustrate a small 
portion of it. 

Let us suppose some disease — say, for example, in the lungs. 
Now, this may be accompanied by certain phenomena ; symptoms, 
as we call them. Let us also suppose, that, in a given number of 
cases, the disease has disappeared under the employment of bleed- 
ing, blistering, antimony, rest, and abstinence. Now it may still 
happen that we may remain in utter ignorance of the laws by 
which the disease had been engendered ; nay, it may happen that 
our treatment has not included any attempt at their investigation. 
Should the latter have been the case, it matters not whether for 
1800 or 18000 years ; it not only explains why our knowledge is 
stationary, but it shews that it is impossible that it should be other- 
wise. But, to return to the case. We wish to enquire, at all 
even4;s, to what agent the cure has been referred, however in- 
different we may have shewn ourselves as to the mode of its ope- 
ration : and here we meet with great difficulty, but it is cliiefly of 
our own making. We have, in fact, employed a number of reme- 
dies simultaneously ; each of which, for aught we know, might 
have been adequate to effect the object. Now, if the effects of 
remedies can, in any case, throw any light on the nature of disease, 
you will immediately perceive how completely all such light is 
extinguished by this mode of proceeding. Had any of the mea- 
sures been employed singly, or if they had, every one of them, 
been used in succession, with certain intervals between each, the 
case might have been somewhat different ; but, to employ them 
all at once, renders any investigation of their separate influence not 
only difficult, but impossible. You will not conclude, from what 



38 



lias just been observed, that 1 am at present recommending any- 
thing with regard to actual treatment in the particular case in 
question. I am only desirous of illustrating what I mean to con- 
vey w^ith relation to the mode in which any investigation should 
be conducted. To illustrate w^hat I mean, still further, I will put 
another case or two. Suppose that I had bled a man largely for _ 
some affection of the lung, and he had got well, — it is quite con- 
ceivable that I might still be ignorant of the mode in which the 
bleeding had acted ; but I should reason much more safely in regard 
to it, than if I had employed sudorifics and purges at the same 
time. Suppose further, that I had observed that, on the loss of 
blood taking place, his skin, which had before been dry, became 
endued with a copious perspiration ; that his pulse became soft, and 
that Ms bowels had acted freely. Suppose further, that I had 
observed that his complaint subsided in proportion as a profuse 
perspiration came on ; or, in another case, on the occurrence of 
free evacuations from the bowels. Suppose further, that this had 
suggested, as it naturally might, m another case, the attempt to 
produce profuse action before I abstracted blood ; and, in another, 
the previous efficient evacuation of the bowels ; and that, in both, 
the subsidence of the symptoms rendered bleeding or any other 
different measure unnecessary : and supposing that other circum- 
stances having led me to the conclusion that, w^hilst many affec- 
tions of the lungs require the abstraction of blood, yet, that the 
unnecessary abstraction of blood was injurious to the animal oeco- 
nomy ; I should at least, quoad two cases, have got some useful 
information ; and, perhaps, not only as regarded the treatment, but 
also the causes of the malady : and all this, not directly, indeed, 
but from a process of reasoning of the easiest kind, founded on the 
simple circumstance of having bled imder provisions which enabled 
me to observe the operations on the oeconomy, consequent on the 
loss of blood ; at least, with this approximation to correctness, that 
they were unobscured by the simultaneous impression of other 
agencies. 

Again, I will put a different case. Suppose I have to treat a 
patient with erysipelas of the head and face, we will say of seven 
day's duration, accompanied by pain in the head, feeble pulse, and 
wiiite and dry tongue. Suppose further, that I bleed the patient 
by cupping him at the back of the neck, prescribe a dose of calo- 
mel and jalap, and give him a saline draught with antimony every 
four hours, order his head to be shaved, and cold and damp cloths 



39 



to be applied to it. In the evening, which we shall suppose to be 
the third day of the month, the pain continuing, I apply thirty-six 
leeches. The next day I am informed that the patient is better, 
but I am not informed w^hat the calomel, jalap, and antimony have 
done : the patient continues to improve, however, until the fifth, 
when, the head being uneasy, I apply twelve leeches to it ; the 
next day, however, I find "a serious relapse of inflamma- 
tion:" the head in pain, tongue white and dry, and skin hot. I 
now take seven ounces of blood from the arm, freely purg© the 
patient, and order him to continue his saline and antimonial me- 
dicines. The next day I find that the erysipelas of the head has 
disappeared ; but that the right leg, on which there had been an 
ulcer, is now hot and painful. I now apply eighteen leeches to the 
leg, and a bread poultice ; and, three days after this, I find the 
inflammation gone, and that the patient may be considered well, 
Now, if I ask myself, what was it relieved the patient ? I really 
cannot tell : it seems that he obtained no permanent relief from the 
erysipelas of the head iintil he w^as " freely purged," and this was 
simultaneously with the abstraction of blood (a very small quan- 
tity to be sure, seven ounces), which had been abstracted before 
without any material advantage, and, indeed, without any, so far 
as we can see, as regarded the erysipelas. Can I venture then to 
say, that the bleeding was of no use ? No, I cannot do that safely ; 
for when the inflammation came on the leg, its relief appears to 
have followed on the application of leeches ; combined, however, 
with other measures. Again, it may be enquired, might not the 
antimony, calomel, and jalap, with the saline medicines, since they 
were in continued operation, have been the really curative agents ? 
I cannot say that they were, because ^ there were other remedies 
employed at the same time : I cannot say that they were not, be- 
cause I have, in my own experience, often enough seen them suc- 
cessful without any other measures. In fact, I can arrive legiti- 
mately at no conclusion ; and therefore, through difficulties chiefly 
arising from the treatment, and not from the disease, I must 
content myself with a selection from certain probabilities ; pre- 
ferring, for choice, that which refers the essential measure, however 
achieved, to the efficient discharges of the alvine secretions : I can 
in no way ascribe the cure to the venisection ; yet the case is 
headed as one so to be considered. When, in a subsequent volume, T 
speak of difl'erent diseases, I shall shew you, by examples, how every 
department of medicine and surgery is poisoned, as it were, by this 



40 



mode of proceeding ; and how often all attempt at correct reason- 
ing is destroyed by the simultaneous employment of various agents*, 
of such a character, and nnder such circumstances, that we cannot 
say that any one, or all the sequences, or their effects, might not have 
resulted from either one of them. It is, in reference to our hopes 
of improvements, consolatory to perceive, that these remarks refer 
to diseases of which our ignorance is the most profound. You 
must not imagine that either of the cases which I have put are 
really hypotheses ; they are occurring every day ; and if you wish 
to see types, or even examples, of them, I should refer you to the 
first list of cases which may fall in your way ; medical, for choice : 
but either medical or surgical will probably equally furnish you 
with the illustrations you seek. 

It must be confessed, indeed, tliat-tliseases oblige us very often 
to be content with the application of whatever knowledge with 
which we may be already provided ; so that it is very rarely, in an 
acute disease, that we can commence an enquiry which has for its 
object the extension of our knowledge ; unless, indeed, where au 
accidental circumstance, such as the refusal of a patient to submit 
to any particular measure, or some other circumstance preventing 
its adoption, furnishes us with an opportunity. This, however, is 
not very unfrequent, and the opportunity it offers should always be 
made the subject of our profound attention. In Dispensary prac- 
tice, the irregular attendance of patients often perplexes us ex- 
tremely in the management, and still more in conducting the rea- 
soning, of cases ; yet the same circumstance often develops very 
interesting results. For example, — sometimes a patient has pre- 
sented himself with inflammation of the eye, with the organ in the 
following condition, — there has been present considerable inflamma- 
tion ; the cornea (the transparent membrane in front) has already be- 
come perforated by an ulcer ; the anterior chamber (the little space 
between the cornea and iris) thus opened, the aqueous humour has 
escaped ; and the iris (the membrane to which we refer the colour 
of the eye) is protruding through the aperture. Now, it is a com- 
mon practice to touch this with caustic ; although I am happy to 
see that Mr. Lawrence, in his Treatise on the Eye, is of opinion 
that it is unnecessary. It is many years since I relinquished this 



* Now all this is opposed to inductive reasoning : nor does this express the 
whole truth ; in point of fact, it prevents our even laying the necessary basis 
of it. 



41 



practice ; and I was first induced to do so, from the result of cases 
such as I have alluded to. A patient having presented himself, 
under the circumstances which I mentioned, finding himself re- 
lieved from the inflammation, relinquishes his attendance, and does 
not come again for perhaps two or three weeks ; when it is found 
that the protrusion of the iris is much diminished, and in all re- 
spects doing, not onlj as well, but much better, than when treated 
in what was at that time the usual mode, and which still continues 
to be the practice of many surgeons ; Mr. Lawrence, no doubt, 
aware of this, has cited Demours' authority, as supporting the 
better practice. In fact, as will hereafter be explained to you, the 
business of the surgeon is to subdue the inflammation ; the pro- 
lapsed iris is managed entirely by Nature. Our knowledge of the 
nature and treatment of inflammation itself, may be improved by 
the due cultivation of accidental opportunity, in the same manner. 
Very recently, a woman applied at the dispensary, with a very 
threatening inflammation of the eye, chiefly affecting the sclerotica 
and iris ; her catamenia were deficient, and there was much pain 
in the head. All this seemed to point very decidedly, according 
to received notions, to the abstraction of blood ; but as the woman's 
general powers appeared to be, from some cause or other, much 
enfeebled, I did not venture on blood-letting, farther than by re- 
commending its local employment by cupping or leeches. She, 
however, refused to submit to either: I therefore embraced the 
opportunity of treating her, with a reference to what might be 
supposed to be the causes (I mean the remote causes) of the in- 
flammation, and the inflammation was successfully subdued with- 
out any of the means usually employed in such a case, except the 
application of belladonna, to prevent, as far as keeping it in a 
constant state of dilatation could do, the occlusion and adhesion of 
the pupil (the hole or window through which light is admitted to 
the eye) by coagulable lymph. You are not to suppose that the 
value of the information elicited from this case, or others of a simi- 
lar nature, is confined to the successful treatment of each particular 
case ; on the contrary, such cases unfold new views with regard to 
the real causes of inflammation, in a manner hereafter to be ex- 
plained to you. 

But to return. If our enquiries, however closely conducted, 
fail of absolute demonstration, it is the more necessary that we 
should be close in our reasonings as to probability. Let me here 
again refer you to cases. 



42 



Some years ago (being already convinced that rlieiimatism, 
although often excited by cold, still usually involved a deranged 
state of the chylopoietic viscera*) I met with a very severe case of 
acute rheumatism, in which I had tried all varieties of treatment, 
dietetic and medical. In about three months, however, the patient 
recovered ; but he appeared to recover just in proportion to the ' 
rectification of the biliary function. This led me to investigate the 
subject of the connection of rheumatism with disordered biliary secre- 
tion ; and, in the first twelve cases that occurred to me, the liver 
seemed to be the primary offender, and the rheumatism retired on the 
restoration of its functions. But what was the conclusion ? Simply 
that disorder of the liver appeared to have caused rheumatism in 
the cases in question, and, by consequence, was to be regarded as 
one competent cause of rheumatism. The conclusion could not be 
safely extended beyond this. It Vv^as probable indeed, that, if the 
liver could thus affect the system, any disorder of the cliylo- 
poieticf, or indeed of any of the other viscera, might, in a person 
so disposed, produce the phenomena of rheumatism ; but the 
grounds on which this probability itself rested forbade the conclu- 
sion that rheumatism was invariably connected with biliary derange- 
ment, although, perhaps, the occurrence of twelve cases in success 
sion might be considered as at least tempting one to that conclusion. 
The fact however was, that, on continuing my enquiry, I found 
that, in many cases of rheumatism, I could in no way discover 
that the liver was at all affected, though in every case there was 



* The necessity of a more philosophical enquiry into the remote causes of 
inflammation will be .spoken of in connection with that subject ; and I hope to 
shew that it promises to be as prolific as the enquiry into the proximate causes has 
proved barren. It is of less consequence to ascertain what is the particular condi- 
tion of the vessels in an inflamed part than to know why that condition becomes 
otherwise than natural. Hitherto we are content to know that the vessels carry 
more blood, and diminish therefore its quantity ; but, after all, this is only attend- 
ing to effects ; the real cause is that which produces the disturbance as a whole, 
not that which gives rise to particular symptoms. Did we know this, we should as 
readily understand why our most active treatment is often unsuccessful, as we do 
why, when successful as regards the inflammation, it occasionally produces such a 
train of untoward symptoms. 

t This term includes all organs engaged, either directly or indirectly, in the 
digestion of our food ; viz. the stomach, bowels, liver, and pancreas, the " sweet- 
bread" of animals. 



43 



sufficient evidence of derangement in some other organ. Now, 
here again the results are important; and, instead of rendering it 
more difficult, thej lead us materially to simplify the explanation 
of the occurrence of rheumatism, in teaching us to regard it as an 
effect which, though it may result from disorder of a variety of 
individual parts, yet resolves its causation into anything which can 
disturb the animal economy. Thus, instead of being disgusted at 
the unsuccessful adoption of some principle which we had hitherto 
found to succeed, we immediately have our eyes opened to the 
explanation of our failure ; we are taught to look at the whole of 
the animal functions, and to direct our treatment to those which 
seem powerfully or primarily affected. 

I had intended, in this first discourse, to enter at large into the 
conduct of our. reasoning in medical enquiries ; to test it by 
the principles of inductive reasoning; and to shew where we 
can and where we cannot carry out those principles ; but I found 
that, to make myself clear, and to do the subject justice, would 
require a volume devoted to it, and that I should be obliged to 
suppose you to be in possession of many facts, the development of 
which will be necessarily the object of fature discourses; although 
I hope to occasionally interweave much more of the principles of 
inductive reasoning than I can do in the present discourse. My 
observations must therefore be very general. 

In testing our conclusions, and the relations they bear to the 
fact, a very useful plan consists in the simple enquiry whether the 
facts ever occur without the consequence which our conclusions 
attribute to them, or the phenomena, comprised in such conse- 
quences, without the facts. For example: suppose a man is 
affected by fever who has been associating w^ith or attending on 
a patient affected by a complaint exactly similar ; and suppose this 
happens, in fifty instances, in the same village ; the conclusion, the 
accuracy of which I propose to test by this method, is as follows : 
I suppose that the patient caught the fever from the man on whom 
he was attending : the facts, then, are — that he was attending on a 
patient affected by the fever, and that he was subsequently attacked 
by the samxe symptoms : the conclusion supposed is that he 
caught the fever as a necessary consequence of the attendance in 
question. I now, then, enquire whether there are any instances 
in which a man became affected with fever, without such attend- 
ance on a person previously affected with fever ; and again whether 
there be any examples of persons who have so attended a patient 



44 



affected with disease, and have yet not been at all affected ; and if 
I find examples of both — that is to say, of persons who have been 
thus exposed not being at all affected — and, on the contrary, of 
l^ersons who have been affected without being so exposed, it is 
evident that my facts do not bear to the conclusion the relation of 
cause and effect which I had supposed. There is either no connec- _ 
tion between them, or there is some link wanting in the one case 
which has been supplied in the other. This seems, 1 admit, very 
simple ; but I beg you to bear it in mind : it is a fact of the very 
first importance in conducting our investigations ; and, in the 
investigation of rheumatism to which I have alluded, it is essential 
in enquiring whether it may not arise from affection of particular 
organs; to enquire also whether the organs in question may not be 
affected without the occurrence of rheumatism ; for, if we find 
that to be the case, the rheumatism may still truly enough occur, 
in certain cases, in connection with disease of that organ, but still 
not as a direct or necessary consequence, but through the inter- 
mediate or previous influence of other causes, such as individual 
peculiarities, &c.; shewing us, in fact, that our conclusion is imper- 
fect, not as having no relation to the fact whence we deduce it, but 
as being without its true and precise relation, in consequence of our 
not knowing the bearing of other facts on it of which we are 
ignorant. 

I will adduce one more example. Inflammation we will sup- 
pose to consist in the simultaneous occurrence of increased red- 
ness, heat, swelling, and pain ; and I wish to apply this mode of 
reasoning to ascertain the essential relations of these appearances to 
inflammation. I begin by redness. Well, I find it in blushing, 
in the ruddy arms of those exposed to cold, in the reaction w^liich 
this cold induces ; but there is no inflammation in either of these 
cases. But again I find inflammation of the transparent front of 
the eye (cornea), and sometimes also of the iris, without any red- 
ness. So here is inflammation without redness, and redness without 
inflammation. I institute the same enquiry as to heat : I find that 
the heat of the surface is often very much increased beyond its na- 
tural standard, both in health and disease, and yet w-ithout any 
inflammation. I find also that, in inflammations, in which I cannot 
distinguish betw^een the ultimate effects, all kinds of heat are ob- 
servable ; excepting only that it never rises much, if at all, above 
the heat of the interior of the animal ; whilst, where the products 
of inflammation take much time for their formation (chronic inflam- 



45 



mation), I often can discover no increase of temperature at all. 
Then, if I consider the law of inflammation, I find inflammation 
without pain, and pain even to torment without inflammation. If 
I consider swelling, I have more difficulty. I cannot always per- 
ceive swelling in parts inflamed, it is true, as in the iris and cornea, 
fascise, etc. ; but many reasons induce me to pause in concluding it 
is not there ; because a very considerable increase of bulk in such 
parts might escape my observation; whilst, in almost every in- 
stance of swelling, I recognize phenomena very much allied in one 
way or other to inflammation. I here pause, inclining only to the 
conclusion, that increase of bulk is hitherto the most essential attri- 
bute of inflammation to which this investigation has conducted me. 
For the tenderness, I find it frequent without inflammation ; and 
occasionally inflammation of the most dangerous character without 
tenderness. On the contrary, inflammation may occur with tender- 
ness as its only external symptom ; as I recollect in a boy who had 
inflammation of the fascia of the thigh, extending to the veins ; which 
suggests another lesson to you, viz. that a symptom may have very 
little relation to the real cause of the malady. The obscurity which 
I have mentioned, as arising from the simultaneous employment of 
several measures, is abundantly exemplified in the number of 
articles usually included in our prescriptions*. The Pharmacopoeia 
issued by the London College seems to me to be by no means 
exempt from this objection ; but it applies with still greater force 
to extemporaneous prescription. A variety of articles are combined, 
some of them having similar properties ; others very different 
ones; and some again having perhaps very little power at all, 
the administration of the whole being followed, in many cases, 
both by success and failure. This will be more particularly exem- 
plified at a more convenient time ; but I may here recommend you 



* It cannot be doubted that, philosophically speaking, the total disregard of an 
inductive reasoning in prescription, tends greatly to impede the progress of science. 
Scarcely a year passes without some new fashionable medicine ; nor any three 
without some one of them going into disuse. Thus, when a new medicine is 
found, it is tried, in a spirit of pure empiricism, in a vast variety of dissimilar 
instances, without, as far as I can perceive, any of those attentions which the 
most common sense suggests as indispensable to any approximation to sound rea- 
soning. Then again, medicines which have been rejected become, like obsolete 
styles in costume, again in vogue ; so that science becomes merged in a pervading 
empiricism. The histories of prussic acid, strychnine, arsenic, quinine, creosote, 
iodine, and even mercury, present, severally, illustrations of one or other of these 
observations. 



46 



generally to adopt simplicity in your prescriptions, if yon wish to 
obtain any real knowledge as to the effects of remedies or the pe- 
culiarities of individuals. If your object be to solicit the function 
of any organ, no matter whether by purgatives, sudorifics, diu- 
retics, tonics, or probilious medicines, let your plan be as simple 
as possible ; and, if you do combine remedies, adhere as closely 
as you can to those with the uncombined properties of which 
you are best acquainted, and which either combine mechani- 
cally only when mixed, or with the chemical combination of which 
you are well acquainted. A rational adoption of such a rule will 
give you ample latitude of prescription, without encumbering your 
reasoning with unnecessary difficulty. I do not mean to say that 
you will never be obliged to depart from such a rule. I do not 
assert that you will never be obliged to employ, in the present state 
of our knowledge, some remedies on grounds purely empirical ; but 
I do say that the occasions will be comparatively rare, and that 
every year will, in all probability, render those occasions still less 
frequent ; and that a sedulous study of what is really practicable, 
in regard to a scientific mode of prescription, will, without involv- 
ing any risk to your patient, not only enlarge your knowledge of 
remedies, but facilitate your enquiries into the causation of dis- 
ease ; and that a recourse to mere empiricism, if you observe and 
practise the other principles which I shall endeavour to explain, 
will be so seldom requisite as to become a very unfrequent excep- 
tion to a general rule. 

In reasoning on probability, of course we include analogy ; for, 
in fact, if w^e examine the principle of probability, we shall find 
that it rests cliiefly on the application of analogy, either real or 
supposed. Now, wherever w^e cannot arrive at demonstration, 
reasoning from analogy is of great service ; but then the analogy 
should, of course, be real. Notwithstanding that probability might 
possibly, by a refined analysis, be shewn to rest on analogy, yet, 
in practice, there is thus much of distinction between them : that, 
w^hilst analogy ahvays implies probability, probability does not 
always imply analogy, in the common acceptation of the term. I 
say then that the analogy should be real ; in plain language, that 
the resemblance on w^hich we reason should be a real likeness. For 
example, I may mention the following. Suppose I wanted to as- 
certain any point with regard to the circulation of the blood in man, 
and that, inasmuch as the enquiry involved the death of the animal, 
I were obliged to conduct it by observation of some other creature : 



47 



what creature should I select? If I am content with a general 
analogy, any animal would answer the purpose, because there are 
certain analogies between all. All animals have more or less 
powers of motion ; all animals have a power of assimilating cer- 
tain extraneous matter to the nature of their bodies ; all animals 
have a circulation of some kind or other : but then they differ in 
many particulars. Their powers of motion vary in a very con- 
siderable degree ; so do theii' powers of assimilation ; and, what is 
more to the purpose, so do their powers of respiration and circula- 
tion. Some animals cannot live in air ; some cannot live in water ; 
some can live in both. Then, as to the circulation : this is con- 
ducted in many very different modes. Some animals have their 
circulation performed precisely in the same manner as man ; others, 
in a mode which we can prove would be, in man, instantly fatal. 
You now see, that, supposing you were to take a dog and a frog, 
you v/ould take an animal m both instances — a being with digestive, 
respiratory, and circulating systems in either case ; but still the re- 
semblance between them would be extremely imperfect. A frog, 
for example, circulates a blood, more than one half of which is 
venous, a condition under wliich a man could not exist for two 
minutes. The temperature of his body is not half that of the 
human subject; and, whilst the human body has the power of 
preserving an uniform temperature under gTeat varieties of heat and 
cold, the power of the frog in this respect is exceedingly limited ; 
all of which relation to temperature is intimately connected with 
the circulation ; as we infer from the fact, that, wherever we find 
the circulation carried on as in the frog, we find the other proper- 
ties which T have mentioned. We find, it is tnie, that both man 
and the frog possess powers of motion ; but nothing can be more 
different than the manner in which life acts in the two creatures. 
Habitually, a slow, sluggish kind of being, the frog moves but a 
short distance from the place where he was born ; but yet, when 
he does move, he lias powers of motion to which there is no 
parallel in man, their proportions being considered. Now, in a dog, 
all these matters are not only much more alike, but the conduct of 
the circulation is absolutely the same with that of man. 1 have 
been thus particular in the illustration which I have adduced, 
because, strange as it may appear to you, it is nevertheless true, 
that many of the reasonings with regard to the minute circulation 
in man have been founded on the observation of frogs, with the 
additional sources oi' obscurity which result from the nervous sys- 



48 



tern, whence all actions are derived, having been placed under the 
torture of experiment ; and from those optical illusions which, in 
such cases, are never certainly separable from microscopic obser- 
vation. 

I will here introduce the few remarks I have to offer on inves- 
tigations involving the dissection of animals which are yet living. ' 
I must confess, that, instead of having afforded any abundant addi- 
tion to our useful knowledge, experiments on living animals appear 
to me to constitute a field the most barren in its products of any 
with which I am acquainted. But, I do not include those investigations 
which merely involve the death of the animal under circumstances fa- 
vorable to examination of particular points : as a short time after eat- 
ing ; in killing it in a particular manner, as by division of the spinal 
marrow, or by bleeding. How many animals, while yet alive, have had 
their spleens taken out ? and with what result ? That there is scarcely 
any organ in the body concerning which we are so thoroughly igno- 
rant. To what have the more or less cruel, and so often disgusting 
experiments of Spallanzani led us ? Are we at all indebted to 
him for any increase of information ? The experiments of Spal- 
lanzani on generation, though they may have produced results 
which might not a priori have been expected, have in no \vay what- 
ever, that I see, added one particle to our useful knowledge. His 
investigations into the nature of digestion are perhaps interesting as 
matters of natural history, and as furnishing tangible illustrations 
of the adaptations of animals to the habits which they are destined 
to observe. But in what way have they really increased our per- 
ception of the intiinsic nature of digestion r or, what is more to 
the purpose, what usefal bearing have they exerted on the progress 
of medical science ? For my part, I do not perceive that they have 
shewn any thing important, but what might have been perceived 
every day by common observation, without any experiment at all. 
I would also here impress the difference between the gratification of 
curiosity, and the cultivation of science. Upon no one subject, 
perhaps, have more experiments been performed on living animals 
than in regard to inflammation, all chiefly with a view to the ascer- 
taimnent of its immediate (technically called proximate) cause : 
but here, again, we are rather more ignorant than we are on almost 
any other point. I cannot put this argument more honestly than 
by referring to Mr. Hunter's experiments ; because there is no one 
for whose mind I have a higher regard, nor any one the weight of 
whose authority would be more likely to influence my opinion. Yet 



49 



I think that Mr. Hunter's experiments on living animals only do 
one of two things ; they are either actually inconclusive, or, if 
they elicit any thing, it is only what is much better established by 
some other fact ; and, in general, by some other fact which Mr. 
Hunter himself furnishes. Now, to the facts established by bleed- 
ing a horse to death, I take no objection ; neither do I see any cruelty 
in an experiment which is necessary every day — I mean the killing 
of horses. When the horse was dead, Mr. Hunter took out por- 
tions of artery from different parts of the body ; and, slitting up 
these different-sized vessels, which were, of course, in a contracted 
state, he measured them. He now wished to know how much of 
their contraction depended on their elasticity (since an elastic tube 
would necessarily contract as far as its sphere of elasticity allowed 
it, when no longer kept open, as it were, by the fluid which was 
wont to flow through it), and how much on their muscular or vital 
power ; since muscular contraction is a property of animal life, and 
elasticity exists independently of it. Having then measured the 
vessels as I have stated, he stretched them as far as their elasticity 
would allow, and took the measurement of their extension. He 
now allowed them to contract, and measured them again ; and the 
difference between this last, the contraction of elasticity, and the 
first, when the vessels were removed immediately after death, he 
considered the degree of contraction depending on their vital or 
muscular power. We shall have to talk of this experiment again : 
it certainly appears very simple and beautiful, and, for the general 
purpose of establishing contractile power, tolerably conclusive. 
The next experiment of Mr. Hunter which I shall consider — for I 
take what appears to me to be the best, and one which involves 
perhaps as little cruelty as any that we know of — was made on a 
living animal. He produced inflammation in a rabbit's ear by 
freezing it ; and, when the inflammation was established (he had, 
to be sure, other views in the experiment, but I take the more im- 
portant evidence at present), he killed the animal. On injecting 
the ears, he found that the vessels of the inflamed one were much 
enlarged, many arteries appearing injected in the inflamed, which 
did not so appear in the uninflamed, ear ; whilst those which did 
carry the injection in both were much larger in the ear in which 
inflammation had been induced. 

Now I have not really any objection to offer to this experiment; 
but I do assert that it is not more conclusive of the fact of the ves- 
sels becoming larger in an inflamed part than many other facts 

E 



50 



which we may observe in our daily practice. Do we not see the 
vessels enlarge under our eyes in ophthalmia ? Do we not see 
vessels now carrying red blood which ordinarily carry colourless 
fluids ? Do we not feel the artery going to a whitlow beating with 
more violence than the one in the opposite finger ? Do we not see 
the veins enlarged returning from an inflamed part ? or do we not " 
feel pulsations in arteries which did not affect our sensations be- 
fore ? and do we not see the part vividly red, there being no fluid 
in the body of that colour but the blood ? If there be anything in 
the medical sciences like demonstration, surely this is it. There 
is no possible objection to it ; whilst, if we were to refine a little, 
the case of the rabbit's ear might be different. The vessels might, 
hy death during inflammation, have been deprived of that contrac- 
tile power*, which muscular parts exhibit after death, and of which 
they are, under certain circumstances, actuallj^ deprived ; and thus 
the same force of an injecting syringe, which in a sound ear would 
only produce the ordinary dilatation of arteries, might easily, in 
vessels so altered, produce a greater distension. I do not mean to 
say that I entertain this opinion ; but no one can say that it is im- 
possible; whilst there is no objection of this kind attached to the 
phenomena which I have instanced as observable in the ordinary 
development of inflammation in the human subject. 

Sir Charles Bell's experiments, by which he showed that the 
anterior branches of the medulla spinalis were nerves of motion, 
whilst the posterior ones were nerves of sensation, have, in my 
opinion, been regarded with more importance than they deserve ; 
although, far from wishing, in any way, to depreciate the labours of 
this accomplished surgeon, few persons can entertain a more real 
respect for them ; and, indeed, were my purpose to carry an argu- 
ment, rather than to advocate the true interests of science, so inter- 
esting do I think the experiments in question, that they are the very 
last that I would have cited ; but, if my object be really truth, if 
it be really to shew that we are, independently of other grave ob- 
jections, misemploying time when we experiment on living animals, 
I ought, in honesty, to select those results which appear to me most 
to favour a continuance of the practice. 

On closer examination, the interest of these experiments re- 
sults from our having been too much disposed to conclude that 

* MlUler, in his recent work on Physiology, seems opposed to the opinion that 
arteries are muscular. Of his arguments I am quite satisfied that the reader should 
judge for himself. See first volume, Mlill. Phys. 



51 



motion and sensation were derived from the same nerves, not only 
without any just grounds, but contrary to a very obvious analogy 
(an example of one kind of obstacle to science mentioned by Lord 
Bacon — Idola Theatri?). We see certain nerves giving us smell, 
others sight, others hearing, others taste, and so on ; and we 
know that we cannot hear by the olfactory, or smell by the au- 
ditory nerve, though these be all connected with the brain ; and in 
the brain, though apparently a single organ, we see mysteriously 
connected, not only numerous, but even opposite, functions, as in- 
tellectual powers, and animal propensities. What right have we to 
conclude that sensation and muscular action were performed by the 
same nerve, any more than sight or hearing ? Surely nothing in 
nature can be more different than is the action of lifting my arm 
from feeling it warm or cold. The two things are, in fact, so 
different, that, in common language, one may be said to convey no 
sensation at all, whilst the other is nothing but sensation. But, 
more than this, we knew that sensation of a part was sometimes 
lost, whilst motion remained, and vice versa — which, with the argu- 
ment from analogy, was a demonstration that the communications of 
the two powers were distinct, even though they had been conveyed 
through nerves whose origins were apparently single. Here, then, is 
another example of how little we avail ourselves of the observation of 
obvious phenomena, of which the Very interest we feel in Sir Charles 
Bell's experiments is itself an illustration*. But in what way has 
our power of relieving disease been increased by the fact, that 
there are, going off from the spine, certain nerves of motion and 
certain nerves of sensation ? To shew, on the contrary, what may 
be done by observation of phenomena, in regard to establishing 
certain distinct functions in different parts, not merely detached 
from the same organ, but forming integral portions of one struc- 
ture, it is impossible not to regard what has been done by Gall and 
Spurzheim with considerable interest. Indeed the history of no 
science has evinced more powerfully how much may be done by 

* Dr. Spurzheim observes that " It was, long ago, remarked that feeling and 
voluntary motion were not always impaired or annihilated simultaneously ; some- 
times the one, sometimes the other, of these functions, was seen to be totally lost, 
whilst the other remained unimpaired. The conclusion then followed, and it had 
already been seized by Erasistratus of Alexandria, that there were nerves of 
motion and nerves of feeling. Pathological facts, therefore, first fixed the atten- 
tion of physicians on this po:nt, as they also gave the first idea of a decussation of 
nervous fibres in the brain, and of the peculiar structure of the convolutions."— 

Spurzheim, Anat. of the Bratti, sec. iii, p. 37. 
E 2 



52 



tlie observation of phenomena than Phrenology ; and I am very 
happy to have so good and so simple-minded an authority as was 
Dr. Spnrzheim, to support my opinion as to the inconclusiveness of 
all experiments on living animals. Phrenology is altogether a mo- 
dern discovery, and a science which seems to stand its ground, to 
say the least of it, amidst a great deal of opposition, prejudice, and 
that very trying test, ridicule. 

I do not wish to be understood as advocating the whole for 
which the phrenologist contends ; still less do I wish to oppose it. 
I know too little of the science to render my support of it worth 
ha\ang ; and, were I so disposed, common sense would prevent me 
from contesting the truth of doctrines, for the due examination of 
which I have not had either leisure or opportunity ; but it is diffi- 
cult for any one who contemplates human knowledge in the circle 
which it forms, and still more to consider the phenomena of human 
nature, without feeling that, whatever errors there may or may 
not be in the details of phrenology, it is, nevertheless, a science 
founded on truth. It is impossible not to perceive how harmonious 
the fundamental principles of phrenology are with all the facts which 
we derive from other sources, whether anatomy, physiology, or the 
more enlarged field afforded by the general observation of mankind. 

We all believe that the brain, as a whole, is the organ in which 
our feelings, propensities, and intellect are seated. The phrenolo- 
logist only contends that different functions are allotted to different 
parts of it. This is exactly what the nervous system shews : nine 
pair of nerves go off to different organs from the basis of the brain ; 
yet can anything be more diversified than are their several func- 
tions ? Then, again, if we examine why we admire the intuitive 
perception of the to TtpeTtov in the Greeks, in the sculptured heads 
which are still extant ; and if we enquire why they put a different 
head on a philosopher and a gladiator, we shall find a practical 
phrenology, — we shall find that a certain district of the philoso- 
pher's head is more developed than that of the gladiator, and that 
this part has a correct general accordance with that part of the brain to 
which the phrenologists would refer their distinguishing peculiarities. 

The phrenologist asserts, that the power of any organ is in- 
creased by exercise, and probably its development also. That 
intellectual, moral, and animal powers increase on cultivation, we 
know ; we see it in the exercise of intellect, in the cultivation of 
moral principles, and in the abandonment which accompanies the 
indulgence of the passions : and we see that the increase of mus- 



53 



cular power, consequent on exercise, is generally attended with 
development of the structure with which the power is connected. 
Thus, muscles increase on exertion, and whenever we find a par- 
ticular sense in an animal highly developed, we have in proportion 
a large development of the nervous structure. We know that, as 
is the bulk of the muscle, so is its power ; but then, not absolutely 
without exception ; since, sometimes a man with comparatively 
small muscles, will be stronger than another man whose muscles 
are larger : and you occasionally see a great muscular fellow, who 
is nevertheless far less powerful than you would imagine. The 
activity of life is different in the two cases. Temperament has 
considerable influence too ; so says the phrenologist with regard to 
the brain. 

The plirenologist further asserts, that developments of particular 
districts of the brain will be ascertained by corresponding deve- 
lopments of the cranium : this position, however, important as it 
is, is nothing more than a necessary consequence of the primary 
propositions, if they be true ; since the very fanction of the 
cranium renders it impossible that it should be otherwise ; masses 
of bone, the result of accident or disease, of course excepted. 
Further, they tell us that all people have all the organs : it would 
be difficult to conceive how we could be responsible beings, were 
any of us deprived of the powers which guide our conduct : but 
they also say that various and even contradictory propensities 
are often powerfully developed in the same individual ; that, 
ceeteris paribus, the actions will be according to the preponder- 
ance of the organ ; and that, when they are equally balanced, 
the conduct will exhibit reciprocal modifications. That is, as if a 
high development of combativeness and caution, for example, 
were to produce prudent activity. Now all this is just what we 
see, I think, in mankind. Lastly, the phrenologists challenge ex- 
amination of the crania of men and animals : and a very interest- 
ing fact is, that the observation of certain manifestations of mind, 
in connection with certain distinctions in form, preceded all 
theory on the subject. These facts, few as they are, seem to me 
to preclude any one from giving an opinion on phrenology without 
a dispassionate examination of it. I have myself seen a phreno- 
logist often give a very good general digest of a man's character, 
whom he had never before seen. Now, that phrenology may often 
fail, in what I may call its craniological application, is no argument 
against the interest which attaches to those examples of its sue* 



54 



cess. It may shew that craniology, or even phrenology, is imperfect ; 
but it does not prove that its principles are untrue : in fact, there is 
no getting over any one well-marked example of its successful ap- 
plication. There seems in it enough of truth, not only to purchase 
immunity from ridicule, but to invite the investigation of the phi- 
losopher. How should we fare in medical science, if every principle 
we consider sound, were disputed because its application was never 
invariably successful ? 

But, to return to experiments on animals, I say that when they 
involve torture, they must be inconclusive ; since the functions, 
through which the vital properties of parts are manifested, are dis- 
turbed from their natural condition ; and I should just as much think 
of deducing conclusions frOm phenomena exhibited when an animal 
is under torture, as I should of estimating the powers of the sto- 
mach by reference to a patient labouring under indigestion. 

If a common headache or toothache will disturb the whole 
animal oeconomy, v/hat may we not expect from the writhing of an 
animal under the torture of experiment ? Is it not flying in the 
face, as it were, of that common sense which is the very essence of 
an inductive pliilosopliy ? 

To waste time, therefore, is bad ; but to misspend it in pursuits 
which have the additional objection of being questionable, in a 
moral sense, is still worse. I rest my objections to them, however, 
on scientific grounds ; but I am not ashamed to confess, that I 
think there is something revolting iu experiments on living ani- 
mals ; and that I can by no means consider them innocent. x\nd 
I am not sure, that even did I know that I could only improve the 
treatment of diseases by experiments on animals, whether I would 
perform them. To advance science in that way has, even when 
looked at in the most favourable view, all the objections of an un- 
disguised selfishuess ; and as it is inlinitely more important how 
ivell we live, than how long we live, the former consideration may 
well outweigh the latter. I have no mawkish sensibility on these 
points: I have made experiments onli^dng animals myself: they 
have not been numerous, certainly ; but I mention it to shew that I 
have not been more immaculate than my neighbours ; but, subse- 
quently, reflection on that subject has presented me with the convic- 
tion, that they are as scientifically unprofitable as they are morally 
improper. Their object is, generally, to discover by the eye, what 
may be safely enough arrived at by better and higher modes of 
observation. We are very apt to trust too much to our external 



55 



senses, and especially to. the eye : now the progress of science has 
been materially retarded by this circumstance ; for the laws of 
Nature are things of a kind which require our intellectual, and 
cannot be trusted to our visual, perception. 

I am not aware of any moral argument which can be urged, in 
favour of experiments on living animals which involve any suf- 
fering beyond that necessary to destroy life, which has not this 
capital objection in limine ; viz. that it assumes the question 
settled, which would determine our right to torture them under 
under any circumstances : which question, I apprehend, it would 
not be difficult to settle in a manner directly opposed to such 
assumption. But supposing, for a moment, that there were some 
circumstances under w-hich this torture were justifiable ; which, I 
repeat, is not the case ; what are we to say concerning the hun- 
dreds of cruel experiments which have been performed, without 
the slightest advantage ? — which shew only, in fact, that numerous 
animals, for whom a variety of benevolent provisions have been 
made by their Creator, have been tortured by man without the 
smallest advantage ; and which, were this the place, might be easily 
shewn to be constructively injurious ; for there is no such negative 
condition as that implied in the term, " without advantage." 
Surely, as Paley would argue, such experiments, however we de- 
duce them, must have been contrary to the will of God ; because 
they have, in no sense, contributed to, but opposed, the happiness 
of his creatures. In plain words, therefore, they must have been 
immoral. Even could it be made to appear, that experiments on 
living animals ministered to our temporal advantages, these could 
not, by any latitude of concession, be allowed as a ground for their 
justification ; for, if they be morally wrong, the supposition that 
they are really advantageous, involves a contradiction since^ if we 
are to believe anything, we must believe that that which is really 
moral, must be really advantageous. I am aware that scruples on 
these points are so little thought of or respected, that they are 
even made the subject of joke and ridicule ; and this, too, on occa- 
sions when men have met to forward the interests of science. At 
a learned society, I heard one gentleman declare that he saw no 
other way of enquiring into the vital processes : but I neither ad- 
mired his science nor his humanity. If we regard experiments on 
animals in their scientific, as contradistinguished from their moral, 
application, our object is not merely to view them with reference 
to what may have been anatomically or physiologically the proxi- 



mate object of their enquiry, but in relation to their remoter, their 
pathological application ; whether, in fact, they have shewn us how 
to prolong life or cure diseases. I confess myself unable to discern 
that they have done either the one or the other. If, then, a mode 
of enquiry be in principle immoral, and scientifically unproduc- 
tive, the two facts reciprocally enforce each other. No one denies _ 
that we have faculties adapted to the interpretation of the laws of 
Nature ; and no one disputes that it is our duty to employ them. 
This latter necessarily implies a free agency, so that we may use 
or abuse such faculties. Now, it would be equally unphilosophical 
and irreligious to suppose that their abuse would be more produc- 
tive than their use ; or, in other words, that the immoral conduct 
of our faculties would be most productive of useful knowledge ; for 
the question is not, whether any ingenious or refined cruelty to ani- 
mals can tell us what we did not know before ; but whether it will 
help us to interpret the laws of Nature : nor is this the whole ques- 
tion ; for the condition must be added, — whether it tells us anything, 
even though it should help us to such interpretation, of which we 
have not sufficient evidence (if we will enquire after it) without such 
cruelty ? The whole argument may be put thus : — that what is 
morally wrong, will prove scientifically unproductive ; and, for my 
part, I see nothing in the whole history of experiments on living 
animals to contradict this position. But if this be a tenable posi- 
tion, how forcible the argument becomes when we regard the time 
thus lost which might have been usefully employed. We see indeed 
how " a cripple in the right way may beat a racer in the wrong." 
But the whole of this subject is so opposed to prevailing prejudices 
and customs, that nothiug short of a work devoted to it (in which 
an inductive digest of all the experiments which have been made, 
and their real bearings exposed, should be included) can be re- 
garded as likely to disencumber medical science of erroneous no- 
tions, arising from the source I am considering. 

In considering the undue reliance which has been placed on 
our external senses in scientific investigations, we may select 
sight ; not because the objections in regard to it are more true, 
but because they are, in practice, more powerful, as having a 
more direct relation to the subject. We are accustomed to believe 
that we receive more information and pleasure from the eye than 
from any other sense, singly considered ; and this, perhaps, it is 
which disposes us to place a reliance on it, to which it demonstra- 
bly holds no just claim. In fact, the subjects it takes cognizance 



57 



of are, for the most part, more gross than those appreciable hy any 
other sense ; for light is to be regarded merely as the external 
condition necessary to the organ perceiving anything, as we know 
by darkness. We can smell, and hear, and taste, with much greater 
real precision than we can see. In health, we never taste bitter as 
sweet, or sweet as bitter ; we never hear an acute sound as a grave 
one, or vice versa ; nor do we refer the odour of the rose or the 
violet to any substance exhaling one of a different or contrary 
character. The eye, however, is continually deceived : the mere 
position of the body will sometimes convey to it very erroneous 
sensations ; whilst the laws of reflection and refraction produce 
such phenomena in certain bodies, as prevent the unassisted eye 
from ascertaining their true positions. Again, the microscope 
informs us of animals so minute in structure, that the naked eye 
can distinguish nothing, even when thousands of them are congre- 
gated together. We might have been warned of the fallibility 
of this sense, even in this factitious extension of its ordinary 
power. Galvanism, electricity, and most of the gases, are abso- 
lutely invisible. The eye, and the other organs of sense, inform 
us of the obvious qualities of things, and of those, probably, 
which are most connected with our necessities : but they never 
acquaint us with their essential characters, except through the me- 
dium of a distinct mental operation : thus we know a thing to be 
hard, soft, pointed, obtuse, rough, smooth, red, white, bitter, sweet, 
&c. but no more : a solid seems to us as if its particles were in 
contact, when we know that they cannot be so. 

The scales of many snakes appear closely in contact, whilst 
the microscope immediately shews them to the eye to be as dis- 
tinct as the particles of matter are shewn to be by the understand- 
ing : in short, if you compare the various illusions presented by 
the external senses, the optical are far more numerous than any 
other ; yet it is unquestionably this sense, the abuse of which 
has done most harm to medical science. Tt is but a few years 
since, and I know not that the idea is every where absolutely 
abandoned even now, that we constantly heard that this or that 
part was not vascular, because we could not demonstrate it by 
forcing into the vessels coloured fluid ; although perhaps the parts 
had exhibited powers of alteration and repair, just as we see in 
other parts of the body : but supposing that such absurd modes of 
reasoning exist no longer, it is much to be feared that a habit, of 
which it forms a part, still continues to vitiate our mode of en- 



58 



qnirj. We find still, men, whose minds might be well employed 
in observing phenomena, directing their eye to the unravelling of 
intimate structure, notwithstanding that so little of really useful 
knowledge has been obtained, with regard to the laws of the animal 
oeconomy, from any researches into the ultimate arrangement of 
structure.* 

In surgery, we every day see examples of the mind being 
misled by the eye, and the consideration of the whole condition of 
the body sacrificed to the observance of some obtrusive character, 
or peculiar arrangement of one of its products ; in the local dis- 
ease, in fact, by which the disorder of the system may be mani- 
fested. 

The whole history of cutaneous diseases supplies little more 
than a catalogue of illustrations to the preceding remark. When, 
on the contrary, the external senses are used with a more measured 
reliance on them, the case is very different ; then they become, of 
course, highly serviceable, and are to be regarded as valuable as- 
sistants. They help us in the collection of facts ; but they cannot 
be trusted in the deduction of conclusions ; they act, in fact, as 
channels of communication from the external world — portals as it 
were to the mind, through which are brought, from %^arious and 
dissimilar sources, materials for contemplation. 

The Mind, having examined the material thus brought, and 
having, in some cases, tested the nature of that brought by some 
one sense, by the examination of some other, proceeds to reason 
on their relations, uses, and the laws by which they are governed. 

* Lord Bacon saj-s, in the introduction to the Novum Organon, that one of its 
objects, in regard to the cultivation of science, " is generally to reject that vs^ork of 
the mind which is consequent to sense" (immediately, as it were), for he adds, " and 
to open and prepare a new and certain ^vay for the mindyrom the immediate percep- 
tion of the senses." Now, from the whole of what he says in regard to the senses, 
it is clear that we must understand this passage as if he had said, we distrust the 
senses in the communication of truth in the interpretation of Nature, excepting 
through the agency of the intellect ; the part of the mind not being its mere and 
direct acceptation from the senses, but through a previous examination, conducted 
on certain rules which I am about to unfold, &c. Again, in Aphor. 50, he says, 
" for sense is a weak and erroneous thing," regarded of course as a substitute for 
mind. In connection, too, with the elaborate employment of the senses, in common 
with other modes equally unsuccessful in unfolding to us the laws of the animal 
oeconomy, and the pervading absence of inductive philosophy, I make one more 
quotation from Bacon, which I think we should well consider : " It is a madness 
and a contradiction to expect that things which were never yet performed, should 
be effected except by means hitherto untried." — Aphor. 6 



59 



I have, however, been led into a long digression from the subject 
with which I commenced this section — I mean reasoning by 
analogy. I can only, however, in these preliminary lectures, ex- 
pose certain principles, which will be more fully exemplified as 
we proceed ; but, in regard to reasoning by analogy, I will here 
observe, that we too often reason in disease from analogies deduced 
from the phenomena of health. Now, in practice, nothing requires 
more caution than this ; there is much of good in it ; but, un- 
guardedly applied, much of error also. I will take the very im- 
portant subject of diet as an example. In health, nothing can be 
more true than that the natural food of ^man is a mixture of 
animal and vegetable food, and that wine and ardent spirits are 
unnecessary ; but, if we were to carry this reasoning into practice 
(I speak not of acute diseases, for there it is not done), in the treat- 
ment of a vast variety of chronic forms of disease, we shall fail to 
relieve many, which a more considerate view of the matter will 
place within our power ; and we shall aggravate others by our very 
endeavours to relieve them. We should recollect then that, for 
the most part, we have to deal with conditions of the system 
wherein we can seldom calculate on the vigorous performance of 
any one function ; whilst, in health, the exact reverse is the case : 
in other words, the analogy is not real* ; and hence that, for the 
most part, in establishing the diet of any case, we shall find it 
necessary to reduce the food even below what in health would be 
a moderate standard : further, we shall have to vary the kind of 
food in a corresponding manner ; some doing better with a diet 
wholly vegetable, others with a diet chiefly animal, with the addi- 
tion of dry farinaceous matter ; and a third class of cases requiring 
things not only useless, but perhaps injurious, in states of sound 
healthf. Now, no generalizations from the observation of healthy 
phenomena will apply directly in the adjustment of these particu- 
lars ; they will conduct our considerations in some measure ; but 
the knowledge of the detail must be the result of cautious experi- 
ment and observation. Mr. Abernethy appears to me to have 
restricted the beneficial operation of the beautiful principles which 
he so successfully unfolded to us, by sometimes reasoning on a 
false analogy ; his generalizations are perhaps the best that we could 



* The desideratum being the adaptation of the agenda to the power ; whereas 
the rule too frequently adopted is an endeavour to raise the power to the agenda. 

t Medicine itself may be regarded as an amplification of this principle. 



60 



have ; but they do not sufficiently embrace the exceptions which 
we meet with in practice. The application, therefore, of a plan of 
diet, excellent in principle, often proves inapplicable to the case, 
and (in hastily judging people) creates a general distrust of its im- 
portance. Now, I shall have ample opportunity of following out 
this and other modes of reasoning, more particularly when I can^ 
exemplify them ; and I shall conclude this discourse by a few re- 
marks on the necessary qualifications of the medical practitioner. 
As these, for the most part, apply generally, I shall dismiss those 
which have been supposed to relate more particularly to surgeons 
in the first place. It is conceivable, indeed, that certain pecu- 
liarities of a physical kind might unfit a man for some of the duties 
of a surgeon, who might, nevertheless, become a distinguished phy- 
sician ; since surgeons are more exposed to disgusting and painful 
impressions than those who are engaged only in the practice of 
medicine. Individuals, so organized, may advantageously restrict 
their attention to surgery, to its study, confining their practice to the 
ordinary duties of the physician. I see no objection to a division 
in practice*, except that it abridges a man's utility. The division 
of study is the thing which is really mischievous ; for, \vhether phy- 
sician or surgeon, I agree with Celsus, " eum laudo qui quamplu- 
rimum percipit." He who selects this or that department in 
practice will seldom attach himself to that for which his nervous 
organization unfits him. In olden times, Celsus spoke of the 
manus strenua stabilis nec unquam intremiscens ;" and un- 
doubtedly coolness and self-possession are very essential ingredients 
in the qualifications of a surgeon ; and we see it occasionally, in 
every one, disturbed, when tested by unforeseen difficulties or com- 
plications. I have seen a great many operations, and have per- 
formed not a few myself, under circumstances of deficient light, 
attendance, &c. ; and I would not believe any man, who had much 
experience in this way, who said that his nerves had never been 
disturbed ; for if he were even devoid of feeling, a rare case I trust, 
still there are various other causes by which such a man may be 
disturbed, but to which men well constituted are not exposed. In 

* A very sensible author (Thompson on Inflammation), in his introduction, 
says, " Di\asion of labour may in this, as in other practical arts of life, be at- 
tended with advantages to society ; but, in learning and in teaching the elements 
of physic and surgery, it must never be forgotten that they are branches of the 
same art (have had the same origin ?), are governed by the same principles, and 
pursue the same object." P. 102. 



61 



fact, there is no greater mistake than that which supposes that ab- 
sence of feeling will supply the place of self-possession. It is a 
very poor substitute. A man's mind will never work more favora- 
bly, either for the examination or relief of his patient, or for the 
plan and execution of an operation, than when it is influenced by 
a manly sympathy for his sufferings, and a single-hearted desire to 
remove them. 

There never was a better or more successful operator than 
Cheselden, and he shews how practicable is the union of skill and 
steadiness with humanity. Notwithstanding that he was so skilful 
and successful, we have his own confession that no man felt more 
before he performed an operation than he did. I cannot myself 
perceive any just grounds for suffering, if a man conscientiously 
does his duty ; but should a man, through his appetite for applause 
or fame, feel so unscrupulous as to the means of obtaining it, as to 
allow that consideration to take the lead of the abstract necessity 
of the operation, he will probably live long enough to discover that 
the best approbation is that of his own conscience. Never perform 
an operation, Mr. Abernethy used to say, on another person, which 
you would not under the same circumstances have performed on 
yourself It is, as it appears to me, a most excellent application of 
the well-known precept ; it is the best recipe I know of, whether 
the interests of the patient or surgeon are considered ; no man's 
hand, if he has sufficient knowledge, will fail of enough of the 
" strenua" or " stabilis," if he make use of it ; it was a favorite 
maxim with Mr. Abernethy, and that which has been said with 
much less truth of some other of his prescriptions may indeed be 
said of this ; viz. that he employed it on all occasions. At pre- 
sent, erroneous notions prevail in regard to our operative depart- 
ment* ; and, until the public are really informed as to the very 
humble claims of mere operative surgery, as compared to the higher 
departments of the science, they will continue to regard it as' an 
efficient test of ability : but the day is fast going by ; such notions 
are visibly on the decline. Operations, however, are in general so 
very simple, that even that attention is seldom paid by the mass to 



* High authority has sometimes been quoted, in regard to operations, which 
would lead to the inference that the surgeon's duty was to study rather how he 
should remove parts than how he should prevent that necessity. I purposely 
avoid recording the expression, because nothing can be more mischievous than its 
dissemination, or more untrue than the proposition which it involves. 



their study which they really require ; and thus what is really due 
to an unpardonable negligence is attributed to the difficulty of the 
operation. Therefore, no surgeon should neglect the study of 
them ; and the simplest mode is to perform all such as admit of 
imitation on the dead subject, and then dissect the parts and see 
exactly what has been done. This, a few times repeated, with the_ 
occasional witnessing of operations on the living, will very soon 
give the knowledge required ; and, for its application, I again re- 
peat, a sound knowledge of your profession, and the moral prin- 
ciple I have above mentioned, are necessary. So much for the 
surgeon : now, then, we will briefly consider the qualifications of 
the medical practitioner generally. I shall not describe any par- 
ticular curriculum for your studies ; how many lectures you should 
attend on this or that subject ; nor how long you should loiter 
about the precincts, or run round the wards, of an hospital ; nor 
the exact quantum of knowledge which you should possess on any 
given branch of science ; for it is of no use to recommend plans 
of study which cannot be pursued in any two instances in the same 
manner ; or rules, of which situation, pecuniary means, and vari- 
ous other causes, will unavoidably vary the observance. It is, 
therefore, expedient to mention such directions as are of general 
application. Regarding anatomy, physiolog}', and observation of 
disease, as your staple commodities, you should endeavour to 
strengthen your mind in its application to them, by as good a 
general knowledge of any other of the sciences as opportunity may- 
place within your grasp, and endeavour to improve and direct your 
mode of observation, by bringing every thing to the bar of common 
sense, disciplined by a careful perusal of Lord Bacon. The no- 
menclature of our profession renders some knowledge of the 
classics necessary ; and, when you are about it, you should not fail 
in getting as great a familiarity with them as you can. They are 
very useful, always ornamental, and often point out a man as worthy 
of confidence to men who employ no other means of forming an 
opinion. The knowledge also of any of the European languages, 
especially French, German, and Italian, will be a very useful addi- 
tion to your acquirements ; wherefore, should any opportrmity offer 
itself of obtaining a knowledge of them, you should be prompt in 
availing yourselves of it. These, however convenient as accesso- 
ries, are not the first considerations ; and, indeed, a knowledge of 
living languages is by no means difficult, at any time, to any one 
who will make the experiment for himself 



63 



In writing discourses which, though not addressed exclusively 
to, are intended to be perused by, young men entering the profes- 
sion, a few words on general conduct seem to me not otherwise 
than proper. If we compare the general deportment of the profes- 
sion, as a body, with any other class in the state, we shall perhaps 
feel no reason to be dissatisfied ; but, on the other hand, it would 
be uncandid to conceal that it may admit of improvement. All 
departments of the study of medicine are certainly of a more or 
less elevating character ; nor can it be doubted that the honourable 
practice of it is equally calculated to advance our moral perfecti- 
bility. One essential thing is, that we should entertain a just idea 
of the dignity and importance of medical science. Unlike many 
others, it derives its rank from its intrinsic value, its extensive 
utility. Other professions derive a portion of their rank from some 
connection which they have, either directly or indirectly, with the 
wheels of government ; and they may assist us in the management 
of our affairs, in protecting us from injustice, or in defending our 
homes from foreign aggression ; but the preservation of health, be- 
sides being of more universal application, is superior to any or all 
of these considerations. Neither of the other professions can, in 
their most successful achievements, confer happiness, if health be ab- 
sent ; whilst, with health, a well-constituted mind can be happy 
under almost every other conceivable privation. In a large em- 
pire, it must necessarily happen that difference of capacity, and 
difference of opportunity, whether for its display or cultivation, 
together with many other things arising out of artificial conditions 
of society, will at one time advance, another time impede, or alto- 
together obstruct, the path to distinction ; but in one thing we may 
be all alike ; that is, the careful study of a portion of those laws 
which an all-wise and beneficent Creator has established for the 
welfare and happiness of his creatures, and in applying them, so 
far as we are able, to the relief of the worst of temporal calami- 
ties. In the dispensation of any power we may thus acquire, we 
should take care that it be sullied by no mean or unworthy motive. 

In a liberal profession, we should not be content with according, 
to those who may give us their confidence, that only to which they 
have a legal claim, but should endeavour to add to it all the lustre 
which humane and social feelings can confer on it. We should not 
consider that we have done our duty when we have prescribed the 
proper treatment adapted to this or that complaint. We should 
make it as sedulously our care to alleviate suifering as to remove 



G4 



disease. Our manners should be artless, kind, and conciliating. 
We should do our best to cheer the desponding, encourage the 
timid, and, above all, to restrain the unwary. Lord Chesterfield, 
who was, as you know, a very good observer of human nature, 
said, that the value of a gift depends a great deal on the manner 
in which it is bestowed. I should be sorry to recommend to you 
such a hollow model for your imitation ; but you may rely on it that 
your advice will, in every sense, be more valuable if given with 
unaffected kindness and sympathy ; I do not mean by a con- 
strained, obsequious affectation of politeness, or a fawning, con- 
temptible demeanour ; still less would I have you assume an absurd 
or pompous gravity ; but by an honest, kind, and patient enquiry 
into your patient's case. I would not inculcate so spurious a mo- 
rality as that which would found our conduct on our interest ; but 
it would be wrong to omit the fact, that that conduct which best 
promotes the progress of virtue is not only most promotive of the 
welfare of our patients, but always in the end of our own also. 
Notwithstanding the high respectability of the profession as a body, 
undoubtedly, like all others, it has its exceptions. We certainly 
occasionallj' see lamentable instances of what I call low tone. We 
are too often subjected to impressions which suggest the humiliating 
idea of a gentlemanly trade, in contradistinction to a liberal profession ; 
and even shocked by examples of the want of that esprit de corps' ' 
which is never wholly absent, among the lowest and most uneducated 
classes of handicrafts. The love of science, and the support of 
the dignity and usefulness of the profession, are sometimes merged 
in a prevailing cupidity ; a desire for fame and display is allowed 
to supersede more weighty and exalted considerations ; and some- 
times the selection of the profession is regulated more by pecuniary 
than by moral or scientific considerations. Men, thus actuated, 
would be more useful in some other departments of a great mer- 
cantile community, where their inclinations might be indulged 
without a compromise of their duties. In diminishing the number 
of any unfavorable specimens of our own profession, nothing will 
have the same power as the force of example. In avoiding any 
temptation to a low tone of conduct, we should endeavour, so far 
as it is possible, to avoid the suggestions of necessity by a prudent 
and economical arrangement of our establishments and our ex- 
penditure ; much greater evils result from neglect of these im- 
portant considerations than are generally supposed ; and it is to be 
feared that, from ignorance, the public indirectly foster an im- 



65 



pro\'idence which they are the first to condemn. To those who 
come to London to complete their studies, I would add a few 
words. Nothing will secure propriety of conduct in the man so 
effectually as a due regulation of it in the student ; young men, for 
the most part soberly educated, and well disposed, are all at once 
plunged into the moral atmosphere of a great metropolis. 

They are thus at once surrounded by all the elements of temp- 
tation, and, with more money at their command than usual, they 
are suddenly Kberated from that restraint to which they have been 
heretofore accustomed. With scarcely any previous opportunity 
for the exercise of self-denial, a student is at once called on to 
exercise it at every step ; whilst he has the power of gratification, 
and is equally removed from restraint or observation. 

Can it then be wondered at, if many are allured from their pro- 
fessional occupations to the waste of their time, the expenditure of 
their means, and to the injury of their health and prospects. The 
best and simplest remedy is an immediate attention to the objects 
for which you come ; a few weeks' steady attention will prevent 
your ideas from being readily diverted from their proper channel ; 
a wholesome fatigue will render the quiet of your home agreeable, 
whilst a growing information will soon supply you with a pursuit, 
which, instmctive only, and even dry, at its commencement, has al- 
ready become an agreeable pastime. In all classes there are some 
idlers, and agreeable companions besides : from a good share of ex- 
perience, and nothing but a desire for your good, I caution you to 
avoid them. I would never counsel the avoidance of rational 
amusement at proper seasons ; I regard it, not only as innocent, but 
necessary. If I had a boy thus situated, I should expect him to 
give me an account of the best actors, the best musicians, and the 
best pictures, at least ; and also some account, at least, of the best 
institutions, w-hether literary or scientific. He who avoids mixing 
with the world in which he is to live, neglects a powerful means of 
obtaining a knowledge of mankind ; and he who avoids rational plea- 
sures only because they are not w-hoUy free from temptations, but 
cuts the knot which he has not firmness or principle sufficient to 
untie. A vicious course is easily avoided at the commencement, 
and a moderate enjoyment of innocent recreation, without excess, 
not only best fits a man for the world in w^hich he is to move, but 
is the best test of moral excellence. 

In our conduct to each other, nothing will conduce more to our 
happiness as individuals, or to our respectability as a body, than a 

F 



66 



prevailing kindness and courteous liberality on all occasions : and, 
in discussing errors, whether professional or otherwise, from which 
no man is entirely free, we should take care that benevolence and 
charity are vigilant over our thoughts, words, and actions. It is 
with real pain that I assert, — but, still conscientiously believing it, I 
will not slirink from asserting it, — that our profession is extremely - 
deficient in this particular. Our kindness or charity towards each 
other is too often referable to partisanship, to nepotism, to private 
friendship, to interest in fact, rather than to those more exalted 
considerations of principle which would dispose us to regard each 
other as Christian brothers, carrjang out our destinies in the common 
path presented by a profession which should elevate our thoughts, 
foster our best hopes, improve our morals, and afford us the noblest 
subject for the exercise of our intellectual faculties ; which should 
induce us to encourage industry, zeal, and conduct, in whatever 
quarter we observe them, however humble ; and to repress and op- 
pose, in a mild but firm spirit, any of a low, mean, sordid, or un- 
worthy character, no matter however high, or, in a worldly sense, 
distinguished the quarter whence it emanated ; for, the higher the 
source, the more extensively polluted the stream ; the more promi- 
nent the example, the more injurious. There is no real charity in 
concealing vice of any kind when its influence is uncontrolled : the 
charity consists, not in this, but in the spirit by which our opposi- 
tion to it is characterized. Should, therefore, any ^dolation of 
principle present itself, whether it regard the rights of mankind at 
large, or those of the Profession in particular, we should never re- 
press, so far as prudence allows us, the expression of a just indigna- 
tion. Should we find, for example, that in any instance, affluence 
and success had still left a prurient vanity insatiate of gratifica- 
tion ; that this led to the performance of professional services on 
scales of remuneration on which no honest man could live, the mo- 
tive avowed, being a desire to do good rather than to make money ; 
we should not hesitate to unmask, if occasion required it, the real 
nature of the case ; whether it be from the cause I have stated, or 
from the pecuniary appetency of trade, which delights in money 
after it has ceased to require it. I yield to no man in the value 
I attach to the really liberal practice of our profession, nor in the 
practical recognition of the pride and pleasure we feel in that 
which most other classes gf men would regard as an onerous im- 
post ; viz. the claim which the poor and wretched have to our 
gratuitous exertions. But that is a widely different thing ; and, as 



67 



the subject is ungracious, I will not amplify it ; I will only add, 
that society is only rendered what it is by the exposure of a certain 
portion of its unworthy members, nor can particular bodies be kept 
respectable by any other means. It is quite certain, that one un- 
worthy member of a profession does it more harm than the conduct 
of twenty good men can rectify. The prevention of improper 
conduct is, therefore, the only means of keeping the Profession 
what it ought to be ; and this can only be done by a habit of dis- 
countenancing any who misconduct themselves, whatever their 
rank, or our own interests, may suggest to the contrary. If this 
were general, men would be more cautious, as the punishment 
would be more certain. Having thus disposed of the considera- 
tion of some preliminary matters connected with the conduct of 
your studies, I proceed to consider the subject of Life in general, 
and animal Life in particular. 

I have thought that a brief recapitulation of each discourse 
would be useful ; and since it is more my object to excite consi- 
deration, than to produce conviction, I would direct the attention 
of the reader to the following propositions : 

1 . Medicine and Surgery constitute not only a branch of natural 
science, but also a capital example of " the connection of the 
sciences," which the expression implies. Their study has not been 
conducted in a proper manner ; they have been too exclusively 
based on an anatomical foundation, more especially as regards the 
development of ultimate structure. 

2. Morbid Anatomy has been invested with an undue import- 
ance ; and has, in fact, been regarded as synonymous with Pathology. 
In connecting symptoms of disease with structural alterations, 
more attention has been paid to the seat, than to the causes of the 
malady. 

3. Analytical examination of our knowledge of medicine renders 
its claim to be regarded as a science doubtful, though it must exist 
as such in Nature. Its surgical branch may, perhaps, furnish an 
exception, if there be room for one, to this remark. 

4. The cultivation of surgery has arrived at a point at which it 
becomes demonstrable that its further advances require the pre- 
liminary improvement of what is more popularly regarded as me- 
dical science. 

5. The progress of all other sciences has been effected by means 

f2 



68 



deducible from the plan laid down by Lord Bacon in his Novum 
Organon ; especially by the philosophical observation of phenomena. 

6. Experience suggests that common and obvious phenomena 
are most promising aids to enquiry ; and that the examination into 
the ultimate arrangement of the mechanism of Nature, as a primary 
step, is rarely, if ever, successful. 

7. That, as regards the ultimate ends of medical science, ex- 
periments on living animals have hitherto proved as scientifically 
unproductive as they are morally improper. 

8. The rules necessary to such enquiry are contained in Lord 
Bacon's Novum Organon. In the absence of this, it is useful to 
regard some simple views as to the nature of facts and conclusions, 
harmonizing with the plan in question. 

9. Violations of these are every where to be found in medical 
investigations. 

10. The evidence of the external senses is to be received with 
caution, and the neglect of this caution has been injurious to the 
progress of medical science. 

Lastly, I have endeavoured to give some hints on the conduct 
of the student. 



69 



DISCOURSE II. 



ON LIFE. 



When we survey a living animal, high in the scale of organi- 
zation, such as man, we observe first the general fabric, of which a 
sketch is given in the appendix. We see a being endowed with 
powers of locomotion ; of assimilating various kinds of substances 
to the nature of its own body, and of converting them, primarily, 
into a fluid convenient for distribution ; with an organ for impel- 
ling such fluid, various tubes for its conveyance to all parts, and 
other tubes for returning those portions of it which are not used, 
to certain centres of vitality, where it may be again endowed with 
properties fitting it for the nourishment of the body. Further, we 
observe powers of converting the fluid into various structures of 
the body ; bone being formed in one situation, cartilage in another, 
muscle in a third, and so on : we observe, also, organs which are 
destined to separate the old material, and provisions for its expul- 
sion from the system. To these is added an apparatus for bringing 
all parts into an integral connection with each other, and for con- 
veying sensations which endow us with such knowledge of the 
external world as is necessary in seeking food or avoiding danger ; 
and which, whilst they accomplish these objects, render the very 
necessities of the animal contributory to its gratifications. We 
find, also, that there is a period of growth, during which the size 
and strength are gradually, yet progressively, on the increase : 
another period, at which the various offices of life are executed 
with a sustained energy ; and, lastly, a stage during which the 
vital powers gradually decline. Motion, assimilation, circulation, 
and sensation in general, become impaired ; and, at length, res- 
piration ceasing, they exist no longer. There may be few other 
visible changes than those to which I have alluded ; but life is ex- 
tinct ; the body becomes immediately subject to other laws, is 
soon resolved into common and more cognizable elements, and 
again mixed with the ordinary matter of the universe. Now all 
this applies to Man, in common with many other animals ; and it 



70 



will be convenient, in limine, to restrict our consideration of man 
to those characters which he possesses in common. 

When death, then, takes place, all the movements of an ani- 
mal machine, so complicated in detail, yet so harmonious in ope- 
ration, cease ; and it has been a very common enquiry, — what is 
the nature of that principle which is gone ? and which, having - 
bound, as it were, the elements of the body together, now leaves it 
subject to the influences which affect matter in general. — Now I 
must say, that I think this enquiry very natural ; and, whether it 
be so or not, certain it is, that the mind will, in some way or 
other, and to a greater or less extent, enter on it, whatever may be 
said to the contrary. If, therefore, you cannot arrest such enquiry 
(supposing that were desirable), it seems very right to endeavour 
to give it a useful direction. 

I cannot participate in the objections which have been urged 
against investigations of this nature ; but as many persons, who 
mean well, are opposed to them, I will venture on a few remarks, 
which may serve to place before such persons what appears to me 
to be the common sense of the matter. I believe it has been one 
of their notions that these inquiries (by engaging the mind on sub- 
jects which they conceive it incapable of understanding) have 
involved it in a confusion which has led to infidelity. 

Now, that the contemplation of Nature — which (conducted in 
a proper spirit) unfolds to us nothing but accumulating evidences 
of infinite wisdom, of the achievement of a vast multiplicity of 
ends by very simple means, of the care which is taken of the 
wants and comforts of every living being, of such an ordering of 
inanimate nature as to render it greatly contributory to the same 
end, and which, further, establishes one series of causes and effects 
referrible only to intelligent agency, and another series of connec- 
tions which demonstrate that there has been only one superintending 
Intelligence — can legitimately lead to infidelity, it is diflicult to 
imagine. To assert this, is to say that it leads to a conclusion at 
variance with all the facts of the subject, and is equivalent to 
maintaining that the whole science of natural theology has no 
foundation. Neither would it be difficult to shew, were this the 
proper place, how an enquiry into the mysteries of Nature pre- 
pares the mind for the proper reception of those of a different kind. 

The kind of investigation which I am considering has some- 
times been called presumptuous ; it has been said that it never was 
intended that our knowledge should exceed certain limits, and so 



7] 



forth. This, indeed, may be granted ; but the presumption is on 
the side of those who dare to prescribe these limits, not of those 
who humbly endeavour to reach them. 

It is scarcely necessary to go farther into this question ; but 
the argument in favour of an enquiry into any part of Nature does 
not rest here ; it is by no means merely negative. The proofs 
that it was intended that we should enquire seem to me just as 
clear as the abstract argument for the innocence of such enquiry is 
conclusive ; and, if there be such proofs, it follows that this inves- 
tigation of Nature is not only vindicable, but that, in proportion 
to our capacities and opportunities, it is an actual duty. Now, 
nothing can be more indisputable than that the Creator has been 
pleased to direct the operations of Nature through certam laws, 
and that many of these are intelligible to man, and to no other 
creature on this planet. Now, why is this superior capacity given 
to man ? It cannot be for mere purposes of our animal economy, 
because it is unnecessary to them. A blind instinct would have 
sufficiently ministered to want, safety, and sensual gratification, as 
we see exemplified in the rest of the animal creation. 

If, therefore, our peculiar capabilities of understanding the laws 
of Nature have no reference to our economy, as mere animals, they 
must have some to our conduct as moral beings ; otherwise, we 
arrive at the dilemma of supposing them to be of no use at all. 
This would be the very acme of error ; for, instead of believing 
that nothing was created in vain, we should be forced to admit 
that, if not the mind, at least its most distinguishing attributes, were 
so created. But even this is not all. When we prosecute an en- 
quiry into Nature, the arguments in support of it thicken at every 
stage of our progress. We are soon struck with the facilities which 
are afforded us ; we are surprised at the analogies between those 
things which are, as it w^ere, laid open to our perceptions, and those 
which we discover by observation and reflection alone. I have 
elsewhere mentioned how frequently the objects of our most recon- 
dite search are typified on the surface of Nature ; such as the com- 
pound nature of light, as exemplified in the rainbow ; the invisi- 
bility of the most powerful agents in Nature, as electricity, &c. ; 
in the very air we breathe ; mechanical adaptation in the whole of 
the animal creation ; our own bodies presenting exemplifications of 
almost every law unfolded by the sciences. The relations between 
electricity and chemical aflinity, though but recently discovered, 
are instanced in the effect which thunder and lightning exert on 



72 



certain fluids, as beer and wine, a circumstance with which man- 
kind have been at all times familiar. The fructifying parts of plants 
appear to me also to be surrounded by every thing that, by attract- 
ing observ^ation, exciting pleasure, or stimulating curiosity, can 
invite investigation ; and we know to what important scientific 
ends the study of such parts has been converted. 

It seems, then, to follow as a necessary corollary to the foregoing 
remarks, that, if evidences exist which are perceivable by man 
only, the ftmction of that organ from which he derives this power 
was intended for such perception ; and that it is, therefore, our 
duty, so far as our capacities enable us, to fulfil this, as well as any 
other end of our creation, to the best of our power. I do not say 
that no harm can result from this or any other enquiry, because 
the injury or advantage of any enquiry depends on the manner in 
which it is conducted ; but I do say that all enquiries into Nature 
are calculated to extend our views and refine our notions with rela- 
tion to the great First Cause, and thus to promote our moral 
perfectibility ; and that, in the search after truth, the great point is, 
so far as the exercise of single-mindedness goes, to be as fearless 
as regards the authority of man as we are humble towards God. 
I will conclude this section by an observation of Lord Bacon's, 
which is quite in point. After saying that an enquiry into Nature 
does not lead to inlidelity, he adds, " for certainly God works 
nothing in Nature but by second causes ; and to assert the contrary 
is a mere imposture, as it were, in favour of God; and offering up 
to the Author of Truth the unclean sacrifice of a lie." 

If an enquiry into the nature of life were to produce no advan- 
tage, unless it terminated in the discovery of that principle, it would 
be perhaps better to relinquish the investigation altogether. If, 
however, it can be showm that the enquiry, however unsuccessful 
with reference to this end, is calculated, when reasonably conducted, 
to disabuse the mind from the influence of untenable hypotheses, 
and to contribute to the accumulation of practical knowledge, the 
case is widely different. We should not, either as teachers or 
pupils, dispense with any inducement to investigate the laws of 
Nature, It is not ditflcult to perceive that this investigation may 
be made practically useful. The very first element in this enquiry 
is of the greatest importance ; namely, the sedulous observation of 
facts which it renders necessary ; for, if you wish to know what 
life or any other principle is, you must first attentively note the 
phenomena it exhibits, in order to refer them to the law und&r 



73 



which thev are developed. Thus, the principle of life is one thing ; 
the laws of its operation another ; and the phenomena, to which 
these laws give rise, a third. For example : a muscle shortens 
itself; that is a phenomenon. When a muscle shortens itself, it 
evinces a power, it obeys a law ; the principle enabling it so to act 
is its life. The contraction of a muscle takes place in obedience 
to a law just as much as the power which it manifests when it does 
contract. Light travels at the rate of a thousand miles in a second. 
This we consider a law : that its angle of incidence is equal to its 
angle of reflection, another. Its division into prismatic rajs is a 
phenomenon : we cannot at present refer this to any law ; and, as 
its refrangibility is modified by particular substances, we cannot 
call this a law, except as regards those substances. However, 
I merely use the above division in its obvious and ordinary 
sense ; and for the purpose of illustrating the conduct of an en- 
quiry. The phenomenon, that is, the contraction, we see : that it 
takes place in consequence of a law, we infer, because we know of 
no exception to its universality as a mode of muscular action ; 
and that both depend on life, we conclude, because dead muscles 
exhibit neither the one nor the other. 

But, in order to obtain clear ideas of the nature of the enquiry, 
we should not restrict our notions of life to mere animal life ; but 
we should extend our observations to life in general. VYe only 
recognize life in an animal imder certain laws. Disturb or impede 
their operation beyond a certain limit, and the animal exists no 
longer. Regarded in this way, every atom in the universe has its 
life ; that is, it is endowed with some principle which subjects it to 
certain laws. An animal has no more. In either case, the dis- 
turbance of these laws does not destroy the' matter, because we 
cannot annihilate a single atom ; but the mode of its existence is 
changed ; it becomes subject to laws apparently different, for they 
cease to produce the same, or, so far as we can see, analogous phe- 
nomena. In this way, we enlarge our survey, by considering not 
only animals in general, but v egetable and inanimate nature ; and, 
being early impressed with the conviction that nothing is accidental, 
but that every thing in nature takes place under some law, we ac- 
quire not only a habit and facility of observation, but also of 
endeavouring to discover the particular law of which every phe- 
nomenon must necessarily be an emanation. 

Now, if we consider the common matter of the universe, we 
see that every atom exists under certain laws. We find that there 



74 



are some laws which all matter possesses in common, and others 
which seem peculiar to different species of matter. We find, for 
example, that the masses are made up of certain parts ; otherwise, 
they would not admit of division ; and, further, that the smallest 
particles have certain wonderful properties : we discover that one 
of these is the disposition to attract to themselves, and to be at- 
tracted by, similar particles (attraction of cohesion), and that this 
power, which seems to increase in proportion to the proximity of 
the particles, becomes so great when they approach very near each 
other that they cannot be separated, unless their attraction be 
overcome by heat, electricity, mechanical or some other force. 
Matter, thus circumstanced, is in the state we call solid. 

Another common property of matter implied, indeed, in the 
preceding paragraph is susceptibility of expansion. If, for example, 
we subject it to a certain heat, its bulk becomes increased ; and 
this could not happen unless its particles were farther apart than 
they were before. When this takes place, we find that, in most 
bodies, the mutual attraction of their particles becomes sensibly 
diminished. If we take a piece of iron, or even a piece of Indian 
rubber, and we wish to alter its shape, we cannot do so without 
hammering, or some such means in the case of the iron, nor 
without the exertion of some extensile force in the case of the 
Indian rubber ; but, if the iron be expanded to meltiug by heat, or 
the Indian rubber be influenced only in a very slight degree by in- 
crease of temperature, we can separate the particles of either with 
great facility. Still the particles cohere so as to form a mass ; but, 
if we apply continued heat, we find that we separate them still 
further, until at last their mutual attraction not only becomes less, 
but actually appears to cease altogether, and they are now as un- 
willing to unite as they were before difficult to separate. This 
last condition is best seen in bodies which can be resolved into 
gases, in which mutual attraction seems to be replaced by mutual 
repulsion. The ordinary law of their existence in a solid form 
seems to be suspended or abrogated. Their particles, separating to 
indefinite distances, meet with other particles which they seem to 
like better ; they attract an<i are attracted by them, so that new 
combinations take place, in which the elements are more or less 
imperceptible to us. Thus, when matter is made to assume the 
form of gas, unless you receive it into closed vessels, it is soon 
dissipated, and escapes your observation altogether. Hence it 
appears that particles of matter are mutually attractive, but that 



75 



this is in proportion to their distances ; and it would seem that, 
when this distance is increased to a certain extent, thej unite rather 
with those of other substances, with which perhaps thej may be in 
closer proximity. 

Now this indisposition to attraction at certain distances is very 
remarkable, and may be illustrated by a form of matter with which 
we are most familiar, as water. Even steam will not resume the 
attractive force necessary to form water, unless heat is abstracted 
from it ; but the tendency to form new combinations is best exem- 
plified by water when it is decomposed. If, for example, we take 
oxygen and hydrogen, in the proportions in which they form water, 
we may conceive that, if we mixed them together in a confined 
vessel, they would combine ; but we do not find that this is the 
case. They have lost something or other on which their capacity 
for union depended; and, in order to restore this capacity, we must 
subject them to some other influence. In their present state, they 
present phenomena remarkably different from those afforded by 
water. Instead of being a ready agent for extinguishing fire, they 
are a most explosive mixture. We find, however, that, if we 
apply flame, a piece of spongy platinum, or electricity in its more 
cognizable form, the particles again unite, and water is produced ; 
so that, by separating the elements of water from each other, we 
have deprived them of their power of reuniting ; and, whatever 
that is, it is evidently the principle by which the particles of water 
were held in combination. Deprive water of this principle, it no 
longer exists as water ; its life, as it were, is destroyed. Now, as 
regards our present knowledge, we have already arrived at an in- 
teresting peculiarity. It is not meant to be inferred that the princi- 
ple subtracted must necessarily be the principle of life ; but it seems 
reasonable to infer that it must be a link in approximation to it. 

We have analyzed the water, and we have reformed it (the 
synthesis of the chemist). Now this synthesis we can accomplish, 
in many instances, with regard to inanimate matter, but never in 
the case of vegetable or animal beings. We will proceed, how- 
ever; only remarking, that (without enquiring deeply into the 
means by which we have reformed the water) we know, at least, 
that one of them was electricity. 

Now, although the particles of matter evince mutual attraction, 
yet this is very different, it would seem, in different kinds of 
matter. The attraction is greater in some kinds than others ; and 



76 



many of those kinds which we are hitherto led to believe to be 
most homogeneous have greater attractions for the atoms of many 
other kinds of matter than for their fellow atoms. A familiar ex- 
ample of this occurs in the attraction between iron and oxygen. 
We know that iron will rust, unless we cover it with grease or 
something which excludes it from the air ; the rust being a combi- - 
nation of the iron with the oxygen of the atmosphere. The ten- 
dency of oxygen to combine with, or to be attracted by, other 
forms of matter is still more remarkable ; most substances attracting 
more or less of it. We arrive, however, at another circumstance, 
if possible still more interesting. x\lthough all substances exhibit 
certain preferences in their attractions (elective affinity), yet these 
seem regulated by certain definite laws ; for even oxygen, which 
exhibits such an appetite for combination, will only combine in cer- 
tain proportions ; and these must be certain multiples of each other. 
Say, for example, that oxygen will combine with one substance in 
the proportion of 8 ; it may possibly be combined with others in 
larger proportions ; but then it will be twice 8 or 16, three times 
8 or 24, and so on. Now this is surely a very curious thing ; and, 
although the present state of chemical science does not give the 
power of demonstrating the fact, yet it seems to render it probable 
that all bodies combine in definite proportions, although these are 
different in different bodies. A very interesting illustration of the 
life of matter is presented in the phenomena of crystallization. 
We see that various substances in a state of fluids gradually resolve 
themselves into accurately defined forms, octohedrons, hexahe- 
drons, and so on, aud that, however finely we may comminute 
them, their smallest particles still exhibit regularity of shape. We 
may dissolve common salt, and see all this. Now how is it that 
the particles of matter are thus brought to marshal themselves 
with such mathematical accuracy ? How do they, in one case, 
assume an hexagonal, in another a pentagonal arrangement ? We 
can only say that it is in consequence of the law under which they 
exist ; that that law was operating in the solution of which they 
formed a part ; and that the principle whence the law emanated is 
either the life of the matter, or, at least, a step nearer to it than the 
phenomena to which we have alluded. When Mr. Hunter spoke 
of the vitality of the blood, many people had great difficulty (and 
indeed it has scarcely yet been altogether overcome) in imagin- 
ing how a fluid of any kind could be alive ; yet surely, if they 



77 



had reflected on wliat life of any kind really is, a very little consi- 
deration of the phenomena of crystallization alone would have 
removed it. 

A very curious property of matter is elasticity. Perhaps no 
form of matter is entirely destitute of it ; hut I allude especially 
to those instances in which it is obviously and highly developed ; 
as in a piece of gristle (cartilage), or Indian-rubber (caoutchouc). 
These substances allow their particles to be separated to consider- 
able distances without destruction of their mutual attractions ; and 
they also allow them to be approximated with ease ; and yet the 
original form is resumed when the pressure is removed. Thus, 
whether they are pulled asunder, or pressed together, their disposi- 
tion to remain at definite distances is unaltered. Resisting com- 
pression by a repulsive, and extension by an attractive, power, 
elasticity seems to represent the most obvious example of power 
in the particles of inanimate solids with which we are acquainted. 
But, after all, nothing seems more strongly to impress on us the 
definite disposition of matter, aad the minute accuracy with which 
the attraction of its particles obey their respective laws, than the 
fusion of various substances at given degrees of temperature. We 
think, perhaps, not much of this fact, because of its very famili- 
arity ; yet, when we reflect a moment on the specific point at 
which their fusion takes place, not merely as measured by the or- 
dinary scales of heat, but with reference to the scale of heat in 
nature, and that the delicacy of their point of fusion is such as to 
baffle all our conceptions of minuteness, we behold, in a most 
striking point of view, the absolute character of the law regulating 
the degree of heat at which solids assume fluid forms ; or, in other 
words, at which the attraction of their particles is overcome. 

Suppose I take a piece of common chalk, which now lies be- 
fore me. It may have formed, for aught I know, in some former 
age, part of some animal ; or I may even have proof that it has 
done so, and has consequently been subject to the laws ordinarily 
governing animal life. It is now, however, a piece of chalk, and 
exhibits no vital phenomena : true ; but it is still subject to laws, 
just as clearly demonstrable as those under which it executed its 
animal functions. In the first place, regarded as a mass, it has the 
common properties of matter, gravitation, &c. It seems to be a 
very harmless solid, and made up of similar particles. But sup- 
pose we pour a little sulphuric acid upon it : what a change is pro- 
duced ! We at once disturb the laws which held its component 



78 



parts together, and elicit phenomena of which we should not, 
a prioriy have formed the most remote idea. 

This apparently innoxious chalk is found to be made up of the 
most active and deleterious principles. In the first place, its atoms 
lose the attraction which bound them together. Some go one way 
and some another. The bubbling occasioned bj the addition of - 
sulphuric acid indicates the escape of carbonic acid gas — a matter 
so far from being innoxious, that, were we obliged to breathe it, we 
should be instantly suffocated. The sulphuric acid combines with 
that from which it has separated the carbonic acid, and an entirely 
new substance is formed. Now, if we examine that with which 
the sulphuric acid has combined, we find that it is just as different 
a substance as the carbonic acid is from any other with which we 
are acquainted. It is, in fact, a combination of one of the most 
powerful agents in nature — oxygen, with a substance called cal- 
cium, and as yet believed to be, like oxygen, an elementary body. 
The constituents of the chalk which we have examined were united 
in definite proportions ; and in that state have exerted a mutual 
attraction so rigid, that their connection has existed, perhaps, for a 
thousand years ; and yet under laws so definite, that the addition 
of a few^ drops of sulphuric acid has dissolved the connection of 
ages. Chemistry, of course, unfolds to us innumerable illustrations 
of the definite nature of the laws governing the particles of matter ; 
and all I wdsh to impress is, that, whatever principle it may be 
which regulates those laws, is either to be regarded as the life of 
matter, or a link in "approximation to it. We are apt to restrict 
our notion of life to existences ^ith w^hich we can connect either 
motion or sensation, and as a conventional term ; or, even as im- 
plying the obvious characteristics of animal life, there may be no 
objection to it. But, when w^e reason on the principle of hfe, it 
seems necessary to regard life in a more enlarged sense, and to 
consider it more in connection wdth that general obedience to cer- 
tain law^s, w^hich is manifested not less in inanimate than animated 
nature. 

Now, if we proceed to the consideration of vegetables, we per- 
ceive another set of phenomena. Some of these present analogies 
with those which we find in inanimate matter ; others appear to be 
altogether different. The parts of vegetables appear to be connected 
by mutual attraction, like those of common matter , and, like it, 
vegetables exhibit certain preferences in their attractions. Some 
prefer one soil, some another ; some require great moisture, others 



79 



scarcely anj^ ; and some classes again evince all conceivable inter- 
mediate varieties of choice. But vegetables display peculianpowem ; 
or, at least, if there be any such in inanimate matter, we have not 
been able, liitherto, to discover them. 

Obscure analogies may certainly be found every where. It 
might be said perhaps, that, in the oxidation of metals, there is 
something of assimilation ; and that the obstacle which the oxide 
itself forms to farther oxidation represents something like a power 
of preservation. We perceive, however, that vegetables have the 
power of directly assimilating various substances to their own na- 
ture ; that is, of taking to themselves new matter ; and that their 
bulk is necessarily increased ; in other words, that they grow ; 
while, if they lose this power, then life is gone, and they become 
resolved into their elements and lost to examination. While inani- 
mate matter seems at present to contain a great variety of elements, 
vegetables are chiefly formed from four; namely, oxygen, hydrogen, 
carbon, and sometimes nitrogen. That these are their chief consti- 
tuents we have every reason to believe ; but that no vegetable con- 
sists wholly of any combination of them is highly probable ; for 
the same reason which prevents us from concluding that oxygen 
and hydrogen alone form water; namely, that we cannot form 
either the one or the other by the simple mixture of their respective 
elements. We require, as I have observed, heat or electricity in the 
case of the water, and something not yet discovered in that of the 
vegetable, which, once destroyed, we cannot restore or imitate, ex- 
cept through the agency of some living individual of the same spe- 
cies, or one of its seeds. 

But, if a vegetable is to preserve its existence, or the assimi- 
lating power on which it so immediately depends ; or if we are to 
produce a new plant from some portion of another, or from its 
seed, we find that certain conditions are necessary. In fact, it is 
essential that there be heat, light, and moisture ; and although the 
degrees in which these are required, vary in different vegetables, 
yet they are necessary, in some degree or other, to all. We prove 
tliis by depriving them, so far as we can, of these principles ; their 
absence does not, singly, necessarily destroy life. Seeds will 
preserve their vitality for years when excluded from light and 
moisture, at least from any sensible degrees of them ; and they 
will also endure excessive cold, though we know of no mode of 
depriving any substance of all heat. Still all of these principles are 
essential to the growth, either of the seed or cutting. The powers 



80 



of assimilation possessed by vegetables are very peculiar. In 
almost every instance, ligbt is essential to them : by a kind of 
refined analysis, of which we can form no idea bnt by its result, 
they appear to derive from light various kinds of colour. 

That this is the essential mode in which their colour is pro- 
duced, we infer from the fact, that if deprived of light, and placed 
under other circumstances not absolutely prohibitory of their 
growth, no colour is produced. Their power in modifying many 
of the most subtile forms of matter with which we are acquainted, 
is also seen in the multiplied v^ariety of their odours : and, if ever 
we arrive at a more perfect knowledge of light, or of the principle 
of odour, it will probably be by some further observation of the 
proceedings of these wonderful chemists. I have said that they 
cannot live without air ; in fact, they respire, and here their life 
subjects them to laws both peculiar and striking. We know that 
the essential element of the air necessary to the life of animals 
is some proportion of oxygen ; and that, whilst they respire air, 
containing about one-fifth of oxygen, they give olf, in expiration, a 
large quantity of carbon. Now, in vegetable respiration, we all 
know that, in the main, these conditions are reversed, — that is, that 
carbon is, for the most part, absorbed, and oxygen given out : — but 
again, there are periods when the contrary takes place ; oxygen 
being absorbed, and carbonic acid being given out during the 
night. We have here, then, so many laws of vegetable life ; 
they operate like other laws, and, if disturbed or impeded, are ex- 
hibited no longer : the principle on which they depend seems, in 
some vray or other, put aside, and the vegetable is resolved, as 
chemistry proves to us, into elements common to itself, and to 
many other forms of matter. All the powers of which I have 
spoken, and I might have added, others equally wonderful, are 
gone ; and the vegetable, which could not only derive nourishment 
from such (Btherial food, but w^hich exerted so refined a chemistry 
on the most subtile modifications of matter, exists as such no 
longer. 

Now, if we proceed to consider animal life, we find that it pre- 
sents some circumstances very analogous to those which we ob- 
serve in vegetables, and others which seem peculiar to itself. In 
the first place, animals can no more exist w^ithout heat, air, and 
moisture, than vegetables ; and we know not any which can be 
said to live absolutely without light, though perhaps there may he 
exceptions. A very remarkable circumstance in all animals, whose 



81 



organization is not so minute as to be altogether imperceptible to 
us, is, that there exists in them a nutritious fluid ; this is also the 
case in vegetables. Indeed, in the most simple form of animal 
existence, the analogies between animal and vegetable life are 
universal and striking ; so that naturalists are not always certain 
where the one begins and the other terminates. 

Perhaps the most peculiar characteristic of animal life, w^hen 
we are allowed to advance a step or two beyond the point at which 
thej appear to blend, is motion. This, however, is very gradually 
developed. A variety of vegetable matters exhibit certain motions, 
w^hich, though they appear to be wholly the result of external 
causes, and to take place without the exertion of any influence on 
the part of the vegetable, yet cannot be altogether thus consi- 
dered. The fructification of many plants depends on the convey- 
ance of the germinating principle from one flower to another : and, 
where this is carried on in the same flower, w^e find, in some in- 
stances, that very decided motion takes place ; the stamina ap- 
proximating to, or embracing, the pistils. A very plain example of 
this is seen in the Calmia. Then, again, some animals scarcely 
move from the spot where they were generated, and possess only 
such limited degrees of motion as enable them to receive food 
which is brought into contact with them, as the oyster ; or have 
certain prehensile organs extending but a small distance from their 
bodies, just a shadowing of increase of motive power, as in Polypi, 
Sea Anemone, and the Medusa. Still, the distinction between 
animals and vegetables generally, is broad and striking, since most 
animals have a decided pov/er of locomotion ; and this, in the ma- 
jority of instances, increased to such extent and variety, that we 
cannot but regard it, on the w^hole, as a very distinguisliing cha- 
racteristic of animal life. Nevertheless, it is always developed 
under laws, although very difl"erent in difl'erent cases. It is but 
small, as I have observed, in the simpler forms of animal exist- 
ence ; but it increases rapidly as the organization becomes more 
complex. In man, we know the power of locomotion to be highly 
developed; but it is much greater in many animals, in fish, in 
many quadrupeds ; still more remarkable in birds ; and perhaps, 
relatively to their size, greatest of all in some insects. When we 
consider the locomotive power of a hawk or pigeon, it seems very 
surprising ; but perhaps is not, on the whole, more so than that 
exhibited by a flea or a grasshopper, or even by an ant or a spider, 
or in some classes of microscopic animalcules. The power and 

G 



82 



rapidity with which motion is developed in these little creatures is 
wonderful, when we reflect a little on the very minute portion of 
matter thus animated: when we consider their activity in relation 
to their size, we can form no conception of any strength or agility 
like it, as resulting from other forms of animal life. A grasshopper 
or flea will probably leap a hundred times the length of its own 
body ; and we are quite lost when we endeavour to explain the 
power exhibited by the ant, in the load which we often see her car- 
rying, so many times heavier than her own body, and this too, with 
a surprising rapidity. 

With motion, the external relations of an animal necessarily 
become increased, both in number and variety ; and we find that 
proportional additions are made to the various sensations by which 
these increasing relations are perceived and discriminated. But, 
although sensation may exist, yet its development is not uniform. 
Of the modifications of common sensation— as susceptibility of 
pain, for example — we have no accurate means of judging ; those 
we have, would lead us to infer that it is very different in difi'erent 
animals : but that this is the case with sensation generally, we have 
clear demonstration. We know that the hawk or the falcon per- 
ceives objects at a distance at which they would be imperceptible to 
other animals. We know that a dog has the power of distin- 
guisliing odours in a manner of which our senses no more enable 
us to form any real idea, than they would if the dog's perceptions 
depended on a different additional faculty. INIany animals— the 
owl and cat, for instance — are enabled to discern objects in so faint 
a light, that we cannot distinguish it from darkness. 

Most quadrupeds have the sense of hearing much more highly 
developed than it is in man ; and they differ likewise, in this re- 
spect, among themselves : the hare surpasses most of them in 
the quickness of her hearing. Even amongst animals of the same 
species, nothing is more common than to find this or that sense 
more highly developed in some individuals than iu others. Then, 
if we take a function which animals possess more in common with 
vegetables, such as the circulation of nutritious fluid, or the power 
of assimilation by which this fluid is renewed, we find that it 
exhibits similar varieties to those observable in functions more 
peculiar to animals themselves. Some animals can assimilate to 
the nature of their bodies (digest) only a simple article, as is the 
case in some insects in their larva state ; some can digest many 
forms, some only vegetables ; some, again, only animal Ibod : and 



83 



others, as man, can digest both animal and vegetable food with 
equal facility. Yet the object is the same in all ; namely, the con- 
version of a certain form of matter into the nature of the individual. 
Some animals have their circulation conducted in one way, some 
in another. In many, the whole mass of the blood undergoes the 
change wrought by respiration, before it is distributed to the body ; 
as in man and the warm-blooded animals. In many, only a por- 
tion of it is changed, as in frogs and reptiles. In some, it is forced 
through the various pipes or vessels by an impelling organ, the 
heart, which may have one, two, three, or four cavities ; or there 
may be no distinct organ of this kind at all perceptible ; yet the 
principle is the same in all. In all, the nutritious fluid is distri- 
buted throughout the body ; and is exposed, in all, more or less to 
air ; in fact, to oxygen gas. 

Some animals can breathe only in air ; some, only in water ; 
and a few, equally well m both* : but the end obtained is the same 
in all. Now, the conclusion to which this cursory survey of a few 
of the phenomena of Nature seems to lead, is first, that every 
thing in creation exists under some definite law ; and that this is 
just as true with regard to any atom of what we call inorganic 
matter, as it is of the most complex form of animal organization : 
secondly, we observe analogies every where. If, indeed, we take 
a highly organized animal, and a piece of inorganic matter, the 
analogies between them are not very striking, though there be 
many things which they evidently have in common ; such as the 
mutual attraction of their particles, subjection to the law of gravi- 
tation, and so on. By resemblances, more or less obvious, all 
things in nature are connected together ; and the connection of all 
parts of creation, with each other, is just as demonstrable as the 
unity of any one individual existence. 

If we consider man, we find that he is at once connected with 
an infinity of other creations by relations and resemblances which 
are very remarkable. In every animal, digestion, respiration, and 
circulation are very analogous phenomena ; in many, they differ not 
from those observable in man, either in principal or effect. In vege- 
tables, we have nutrition, respiration, and circulation ; and, in inani- 



* Amphibia, generally so called, are not here intended : these really breathe 
only in the air ; but the Proteus and Draco Volans are truly amphibious, having 
both gills and lungs, and appearing to breathe indifferently in air and water. 
Crocodiles, Turtles, ike. breathe in the air only. 

g2 



84 



mate nature, the component atoms of bodies are subject to laws not 
less rigid or definite. All matter, whether animal, vegetable, or 
inanimate, is equally indestructible ; all matter has a certain dispo- 
sition to preserve its life in the form in which we find it in nature, 
until acted on by influences external to it, the particles of its masses 
cohering by mutual attraction : all matter has certain tendencies - 
towards other matter. The result at which the mind arrives from 
this kind of contemplation, is, that the life of every thing, or, at 
least, that principle which immediately governs its phenomena, may 
be the same. 

Now, what this principle is, is a question that in all probability 
will never be answered, otherwise than by a description of phe- 
nomena which are produced by it. Our knowledge of these, 
however, may not only be very much increased, but it may include 
the ascertainment of a vast variety of relations, M^hich are at pre- 
sent altogether unknown to us. It is very conceivable, for example, 
that something like electricity may be the motive principle in living 
actions ; nay, more, it is conceivable that we might ascertain its 
different distributions or forces to be productive of one kind of life 
in one form, another in another, and a third in inanimate matter, 
and yet that we might be as ignorant as ever of the cause of this 
particular distribution ; yet, what a wonderful addition would this 
make to our knowledge of its laws I I have no intention of entering 
on a consideration of the various hypotheses concerning the nature 
of lue. You probably know that it has been supposed by diiferent 
persons to depend on some subtile principle* to which various 



* I purposely forbear to speak of agencies as material or immaterial. As for 
materialism or imraaterialism, are they not, after all, words without ideas ? They 
both appear to me to be little more than fanciful distinctions, founded on a grossly 
erroneous and exaggerated estimate of our perceptions. Who shall dare to mark 
the line between these two hypothetical divisions ? there may be thousands of 
forms of matter of which we have no senses to enable us to take cognizance, or 
form the most remote conception, whilst those substances which we should imagine 
the grossest or most palpable, may be resolvable into some of such inappreciable 
principles. If our knowledge teach us not, our very ignorance should demonstrate 
the absurdit)', I had almost said the impiet}', of our presuming to establish such 
di\asions as those implied in the words material or immaterial. The contemplation 
of electricity alone is, one would think, sufficiently humbling : in which division 
should it be placed P Where, in the boundless range of Creation, do we not find 
its presence suggested to us ? Where can we say that it is not in operation ? If 
it is to be immaterial, with what form of matter is it not combined? or, if mate- 
rial, how does it range itself under any of our definitions of matter ? The notions 



85 



names have been applied ; but, as all these seem to me to signify 
nothing more than the truism that life must depend upon something, 
I shall not stop to consider them. 

The idea that life depends upon organization is more tangible. 
If this mean anything, it must mean that life is the emanation of 
the mechanical arrangement of the minute particles in the bodies 
in which it resides. Now, a priori, this view might have been as 
easily conceived, perhaps, as any other ; since we must believe 
that it would have been as easy for the Creator to have produced 
life, as the result of mechanical arrangement, had it so pleased Him, 
as in any other manner ; neither would it have been difficult to 
have conceived life as arising out of some form of matter, since we 
are not obliged to limit our notions of matter to our perceptions of 
it. But the facts we see daily before us not only render it difficult 
to believe that life arises out of organization, but (for the plainest 
possible reasons), appear to render it impossible ; since, instead of 
organization producing life, if there be anything clear to the eye of 
reason, it is that life produces organization. 

Now this is not, perhaps, a thing that admits of absolute proof, 
because we never find life and organization really separate. There 
is really no such thing as an inorganic substance in nature : every 
atom has its relations ; and the most complex organizations are 
but the accumulation of such relations : but we see that life has the 
power of modifying organization ; it can convert inanimate into 
vegetable, vegetable into animal, animal into vegetable matter. It 
can convert a seed into a plant, an acorn into an oak, an egg into 
an animal ; and a mere spot of animal matter into man — an intel- 
lectual being. Besides this, in a seed, life seems to exist without 
organization ; in a dead animal, organization seems to exist without 
life. In fact, the relations between life and organization appear to 
me to be viewed in the most true light when they are viewed most 
simply. The principle of life, mysteriously modified, may be the same 
every where. Organization seems to be merefy the mode through 



usually annexed to the terms materialism and immaterialism seem to proceed on a 
supposed power of analysis to which the human mind is wholly unequal. The one 
results, as I have already observed, from an exaggerated estimate of our physical 
perceptions ; the other, from an abortive endeavour to supply their acknowledged 
deficiencies by the exercise of imagination. Were we to agree that the property 
of matter is the occupation of space, imponderability, mobility, and inertia, — 
what form is impenetrable by heat or electricity ? or shall we say that electricity 
is imponderable because we cannot weigh it ? 



86 



which life impresses ou different forms of creation their charac- 
teristic peculiarities. This seems further probable from the cir- 
cumstance that all the functions of animals are, in principle, the 
same ; while there is great variety in the mechanism by wliich they 
are carried into effect. In fact, to call the phenomena exemplified 
through the organization of an animal its life, is to confound two 
very different things. It is as if we should consider the effects of 
heat, for example, to be identical with the matter that we call 
caloric, which produces them. That matter, placed in certain me- 
chanical relations, will produce certain determinate effects, may be 
very true ; but what is it that so orders the atoms of this matter to 
assume certain definite forms and relations, not only to each other, 
but to all other matter in the universe ? If we admit that a certain 
arrangement of atoms in a muscle, tendon, or nerve, produces re- 
sistance, contractility, or sensation — that another arrangement 
produces the leaves and flowers of a plant, with their various shades 
and odours — and that a third arrangement produces, in one case, 
chalk or marble — in another, charcoal or a diamond — still the ques- 
tion recurs, to what principle is the peculiar arrangement owdng ? 
what is it that disposes certain particles of matter so to marshal 
themselves as to produce, in one case, bone, tendon, muscle, or 
nerve — in another series, wood, leaves, flowers, and various odours 
— and in a third, the several kinds of inanimate matter ? 

The aggregation of phenomena which they respectively exhibit, 
and the laws observable in the development of these phenomena, 
may well enough be called the life of the respective individuals, as 
expressing, in one word, the assemblage in question ; but the mo- 
tive principle, on which their primary constitution depends, is no 
more expressed by the term, than the moving powder of a steam en- 
gine would be explained, to a person ignorant of steam, merely by 
a description of the effects wrought by the machine in question. 

Further, I cannot tliink that those approach much nearer to the 
truth who speak of life as some subtile principle superadded to 
organization. For here the former question recurs — how is the 
organization itself generated ? what is it that disposes particles of 
matter to form the various structures of a living body ? for, to 
suppose that one principle effects the formation of structure, and 
another gives it a vital power, not only involves a purely gratuitous 
and a highly improbable assumption, but, as supposing more causes 
than are necessary to produce the effects, is unphilosophical and 
contrary to all analogy. It has been suggested by Mr. Abernethy, 



I 

I 



87 



iu advocating Mr. Hunter's opinions on the subject, that hfe may 
have been added to organization in the same manner that electricity 
is to a wire in an experiment ; but this is passing over the diffi- 
culty, since it dismisses altogether the question, how the organization 
itself was evolved ? Therefore, if such a principle be the life of 
an animal, it must have influenced the arrangement of its atoms 
as well as the phenomena w^hich they exhibit when arranged. This 
may certainly be true ; but that electricity, or any other principle, 
should have been superadded to organization already developed, 
seems, in the highest degree, improbable. 

If, however, our enquiries into the nature of the living principle 
should only produce a negative result, in the present state of our 
knowledge, and determine only what is not life, still it disabuses 
the mind from error ; and, in many subtile enquiries, experience 
shews that the determination of what this or that thing cannot be, 
enables us, by contracting the field of our enquiry, and by disen- 
cumbering the object of our consideration, to arrive at the discovery 
of its real nature. That this will never happen with regard to the 
living principle is very probable ; but the hope that we may, by a 
course of reasoning which often discovers the real nature of many 
things, approximate more closely to the knowledge of life, seems 
far from being unreasonable. 

Now, if the contemplation of Nature unfolds to us that all 
atoms in the universe are mutually connected by their relation to 
some law or other (and the unity of the First Cause is clearly de- 
monstrable on this kind of evidence), it follows, a fortiori, as a 
matter of high probability, that principles, which we have reason 
to believe the most universal in their operation, must be, in some 
way or other, connected with so large and so important a part of 
creation as that represented by animated beings. 

We often find in books, and books of great character too, this 
or that being, spoken of as more beautiful or more perfect than 
another. We may be excused when we smile at such implied at- 
tempts at comparison ; but it is quite conceivable that, with a 
pervading perfection in all beings, some may be in their uses more 
or less subordinate to others. We cannot fail to be struck with 
the evidence that the animal creation, viewed in this way, holds a 
very high rank in the scale of existence ; and this, whether we re- 
gard the provision which is every where evident for the supply of 
their wants and gratifications, or the power which they evince in 
availing themselves of such provisions. The arguments for the 



88 



rank wliicli they occupy might be extended far beyond the limits of 
any work not expressly designed for such a purpose ; even those 
furnished by the geological history of the globe are sufficient for a 
A'olume. That animated beings j ield to no other class of existences 
is at least sufficiently evident. 

Now, then^ if we consider those principles which appear to be 
in the most universal operation, the progress of enquiry seems 
always tending to diminish their number, until, at length, they ap- 
pear to be very few. In fact, of principles we scarcely recognize 
the universal presence of more than two ; and these we find evi- 
dent every where : I mean gravitation and electricity ; but, as the 
former seems to be much modified by the relative distances of the 
particles of matter to each other, and by other circumstances, hav- 
ing very remarkable relations to electricity, it becomes, indeed, 
very doubtful whether they are not one and the same thing. We 
may, at least, reasonably infer that electricity is the most pervading 
principle in nature of which we have any cognizance. To consider 
electricity in all its known relations, either of power or analogy, 
would lead me very far from the present subject ; but it may be 
useful to mention a few of them. 

If I suspend, by means of a piece of dry silk, a light sub- 
stance — say a ball of paper, or a ball of very thin Indian rubber — 
and then rub a glass rod perfectly dry with a piece of silk covered 
with a little amalgam, and if I now make the glass rod approach the 
paper ball, I find that it first attracts the ball, and then causes it to 
fly off or be repelled. The ball that hung by the silk, in obedience 
to the laws of gravitation, gravitates no longer ; motion is commu- 
nicated to it, and this in various senses, according to the direction 
in w^hicli T hold the glass tube. Now the remarkable thing here is, 
that the electricity suspends the law of gravitation — suspends, in 
fact, the operation of a law which ordinarily pervades everything 
in nature. To estimate the importance of this simple phenomenon, 
we must recollect that the law of gravitation is that which holds 
the celestial bodies in their orbits, just as certainly as it enables the 
chalk before me to lie upon the table. But, however extensive our 
idea of the powder or influence of electricity may be, from the con- 
sideration of this circumrstance, we find that farther examination 
tends only to confirm our conviction of its universality. Sir Hum- 
phry Davy shewed that the various phenomena in the inorganic 
world, included under what we call chemical affinity, really de- 
pended on actions which were electrical ; and, although it has not 



89 



yet been shewn tlrat all chemical actions are demonstrably electri- 
cal, yet enough has been done, not only to render it in the highest 
degree probable, but, I believe, to leave no doubt on the minds of 
those who are most capable of judging on the subject. Sir Hum- 
phry Davy shewed, that, if an alkali be endowed with certain elec- 
trical properties, it can be made to pass through an acid without 
change — a palpable suspension of the laws of chemical affinity. 
The power, too, which electricity has of decomposing many bodies, 
shews that it also possesses the power of overcoming chemical 
attraction. The exertion of this force, as one purely electrical, 
has been, I think, still more demonstrably shewn by Mr. Faraday, 
who has effected decomposition with Voltaic electricity without 
contact. Further, it may be shewn that chemical actions, when 
excited in any other way, are attended by a disturbance or evolu- 
tion of electricity ; the various phenomena thence resulting, consti- 
tute what is called electro-chemical science, which, if it do not 
demonstrate, induces us to conclude, on the ground of a most rea- 
sonable probability, that all the attractions (of which I have before 
spoken) between the atoms of various kinds of matter, and con- 
sequently all the phenomena of chemical affinity, are, in fact, de- 
pendent on electricity. 

The consideration of the dependence of vegetable life on air, 
moisture, heat, and light, suggests to us, in the strongest manner, 
the presence of electrical agency ; as regards air and moisture, from 
the general influence of electricit}^, and, as regards heat and light, 
from certain peculiar analogies wMch are evinced between electri- 
city and the two last-named principles. The greatest heat which 
we are capable of produciug is obtained through the direct agency 
of electricity ; nor is the light, which is directly derivable from it, 
less remarkable. The rapidity of its motion is so great as to be 
absolutely beyond our perceptions : we are wholly incapable of 
measuring the interval of time during which it travels from one 
end of a wire to the other. There is nothing like this but the ra- 
pidity of light. The fact, too, that the different prismatic colours 
have different electrical properties*, and these in some relation to 
their re'rangibility, is another fact which strongly suggests to us the 
existence of some mysterious yet certain connection between light 
and electriciy. The experiment, also, of the Abbe NoUet, as re- 
lated by Dr. Priestly, in his History of Electricity, shewed that 



See Mrs. Somerville on the Connection of the Sciences. 



90 



vegetation was decidedly accelerated by electrification ; so that, 
however obscure its mode of connection with vegetable life may 
be, there can be no doubt of its presence or its agency. I have 
thought that our knowledge of the relations of electricity to light, 
and of light to colour, might be extended, if flowers were made to 
blow under various prismatic colours, and under different electrical 
influences ; but, although the proposition has been thought promis- 
ing, I am not aware that any experiments have hitherto been made ; 
and I regret that I have neither time nor convenience for conduct- 
ing them myself 

The consideration of animal life in connection with electricity 
unfolds so many circumstances, bringing them into certain intimate 
relations, that the presence of electricity in an animal body can no 
longer be doubted ; and, if the subject were to be pursued in the 
spirit which advocates a particular opinion, it would not be very 
difficult to shew, that, as electricity is the next power in regulating 
the laws of chemical affinity, so is it the highest link as yet disco- 
verable in the chain of causes between the principle of life and the 
phenomena which it unfolds to us. 

But my desire being rather to remove erroneous impressions 
than to establish any particular doctrine, rather to prepare your 
minds for truth than to pretend to furnish you with it in this 
matter, I shall simply state one or two facts evidencing the connec- 
tion of life with electricity. The general probability of such con- 
nection I have already inferred, from the universal agency of elec- 
tricity and the ubiquity and importance of animal life. The par- 
ticular evidences are, perhaps, more striking. You have seen that 
electricity suspends the laws of chemical affinity, and this, both by 
preventing the separation of parts, and also by effecting, on the 
contrary, their decomposition. In both of these respects, the ac- 
tions of life are equally remarkable. If a piece of animal food be 
presented to the stomach in a state of commencing decomposition, 
this process is stopped previous to the solution of the food by the 
stomach's peculiar actions. 

As its solution proceeds, it acquires new properties, and is ulti- 
mately converted into all the various parts of which the body is 
composed. The rapidity of the actions of life is very great, and 
especially in the conveyance of sensation. An impression is con- 
veyed to the mind from a distant part of the body ; the part is 
moved, in consequence of that impression, by a mandate from the 
brain ; and all this takes place in an instant. Yet nothing is more 



91 



susceptible of proof than that the impression and command must 
have travelled from the foot to the brain and from the brain to the 
foot ; nor anything more demonstrable than that the nerves were 
the media through which they were conveyed. Now in electricity 
we have the same rapidity of motion ; so that, if it be not really 
the instrument of communication, it would, at all events, appear to 
be one not inappropriate for such purpose. When we touch the 
trunk of a nerve, and disturb its life, we feel a sensation like that 
which is imparted by electricity. 

The two sensations, as such, are identical. We cannot restore 
life by the agency of electricity ; but we can produce effects which 
are exceedingly like vital phenomena. We can make muscles con- 
tract, after death, by electricity ; and even the chemistry of the 
body has been, in a degree, continued by the same agent"^. More- 
over, as we can thus renew by electricity muscular contractions 
after death has taken place, so can we, through the same agent, render 
ordinary contractions more vivid whilst the animal is yet living. 
So far, however, as regards some kind of connection between life 
and electricity, we are not obliged to rely on mere general analo- 
gies ; since, in some animals, electricity is as plainly developed as 
in a Voltaic battery — there being, in fact, a power in the animal of 
giving electric shocks, as in the Torpedo and in the Gymnotus 
Electricus. 

Now this, I suppose, is what Lord Bacon would have called 
a glaring instance ; and, as it is one which is calculated to lead to 
some error, I shall speak my sentiments on it very unreservedly. 
When w^e consider the universality of electricity, and still more 
the powerful agency which it unquestionably exhibits in animals, 
and at length arrive at the discovery of an animal endowed with 
direct electrical properties, our growing conviction of the intimate 
connection of this principle (electricity) with that of life, is apt to 
end in the conviction of their identity. I do not mean to assert 
that they may not possibly be the same ; but I do assert that the 
facts do not justify the conclusion; and least of all that one, 
which is perhaps of all the most striking, namely, the presence of 
electricity in an organized body. We see, in the electrical organ 
of a torpedo, an abundant supply of nervous matter ; and the 
arrangement of the matter presents, indeed, analogies to the Voltaic 



* Dr. W. Philip, in The Philosphical Transactions, and in ExperimcDlal 
Enquiry into the Laws of the Vital Functions. 



92 



pile : several very large nerves are distributed to it ; but the appa- 
ratus itself, and the power which it develops, are just as much 
parts of the animal, and products of life, therefore, as its liver, 
stomach, or any other organ, with their functions. 

Therefore, the circumstance of a particular organ evolving 
electricity in an animal, no more justly allow^s us to conclude that - 
electricity is life, than the presence of a liver, a stomach, or a musk- 
bag, would authorize us in stating, that either bile, the gastric 
juice, or musk, was the vital principle. On the contrary, we 
should rather conclude that, inasmuch as these, and therefore elec- 
tricity in common with them, are products of the living principle, 
they must be subservient to it. Although it should be admitted 
that this function in the torpedo, and the universal residence of 
electricity in animal bodies, prove the analogies between life and 
electricity ; or that electricity is some principle more proximate in 
its nature to animal life, than any thing else of which we are ac- 
quainted ; we are far from having arrived at the establishment of 
their identity. The only conclusion to which we can reasonably 
come, is, that electricity is subservient to life, or to some superior 
law, w^hich regulates it in one way in the inanimate kingdom, in 
another in the vegetable, in a third in the animal ; and that it is 
so entirely under its influence in the torpedo, as to be evolved by 
it from a living battery. That electricity may be a vital agent in 
all, is perhaps probable ; but whatever so variously regulates the 
electrical powers, whether it be in the original laws governing the 
atoms themselves, or in something which measures or directs the 
electrical agency, must evidently be, if not the vital principle, at 
least something a link nearer to it than electricity itself. 

Indeed, it is obvious enough, that the mere superaddition of 
electricity does not constitute life ; for if electricity be allowed to 
be the agent in building up the structure of the body, or in ex- 
citing its functions, still the question recurs, how such a subtile 
principle should be regulated as to produce phenomena so deter- 
mined, and yet so different in the different orders of existences. We 
are here obliged to refer to some superior agency, just as we are 
when we moot the question of definite quantities or chemical affi- 
nity. Those who can imagine no other secondary agencies, would 
at once refer to the First Cause — the fiat of the Creator. I am 
far from tliinking that we have reached such a height in knowledge 
as to justify us in considering that we have arrived at the ultimate 
link in the chain of causation : indeed, I instinctively shrink li'om 



93 



such a conclusion, as one fraught with presumption ; and I believe 
it to be one, which those who think most, would hesitate most in 
adopting. There may be principles in Nature, for ought we know, 
that we not only have not yet discovered, but of which we have 
no idea ; our knowledge, even of electricity, as compared with the 
age of the world, is itself but an affair of yesterday*. 

I shall pursue this subject no farther; my object has been, 
merely to prevent your minds from being influenced by untenable 
hypotheses, and to shew that there is no one theory, as to the 
nature of the vital principle, on which we can safely rest a con- 
clusion. But the sooner you contemplate the phenomena of life, 
the sooner you will be employed in the acquisition of knowledge 
professionally useful ; whilst, as I have before observed, you w^ill 
be occupied in that kind of enquiry, w^hich, with regard to life 
itself, promises to lead us to the purest notion, if we are ever to 
arrive at any, of its real nature. 

What we have to do with life is to study its phenomena, with 
a view to ascertain the laws to w^hich they are to be referred, and 
to regard the body as the arena of their operations. It may be very 
necessary to examine the structure or mechanical arrangement of 
the different parts of the body (anatomy), to trace their uses 
(physiology), and to observe their different appearances in disease 
(morbid anatomy) : but all, or any of these, are only useful in 
proportion as they are subordinate to, or as they facilitate, the con- 
templation of the body as a whole. I wish most particularly to 
impress this on you, because, on your having a due and deep con- 
viction of it, will not only depend your acquisition of that which 



* So, with regard to heat, — nothing is more impossible than to separate heat 
from life, — we know of no instance of life without it ; and, on the other hand, we 
see the most striking proofs of their intimate dependence or connection. Not the 
least circumstance is, the universality of the connection, not only with one, hut 
with every kind of life : but when we are carried by these considerations to that 
point which involves the question of whether heat is life, we find the very same 
difficulty as we do in regard to electricity. What is it, in fact, that makes the 
heat of one temperature essential to such vast numbers, which would certainly 
destroy equal multitudes of other creatures ? Whence results the wonderful and 
varied power which animals possess of maintaining their characteristic heat 
in media of such varying temperature ? All these, and many other queries, 
oblige us to suppose, nay, to be convinced, that something must regulate these 
pecuUarities ; and whether that be life or not, it is obviously one link in the chain 
of causes nearer to it, than is heat abstractedly considered. 



94 



is at present attainable, but, I verily believe, any chance of extend- 
ing the bounds of real science. 

You are to observe how the body is influenced by various ex- 
ternal causes — by the air we breathe — as characterized by varieties 
of heat, moisture, or any peculiarity by which it produces effects 
on the surface of the body ; secondly, you are to observe how the 
body is affected by articles introduced into the stomach, whether 
they be food or medicine ; and, thirdly, you are to observe the 
influence of moral causes. Of these we see certain types in other 
animals, it is true ; but they occur with much greater force and 
frequency, and in much greater comphcation, in man. However 
various the agencies external to the body, which produce disease, 
may be, there is the strongest reason for believing that they never 
produce disease in all those who may be subjected to such agencies. 
The most prevailing diseases, or the most fatal epidemics, equally 
support this assertion. Neither do we And that these agencies 
produce disease, even in the majority. Perhaps we have hardly 
one authenticated instance in wliich the most deadly epidemic did 
not leave more persons untouched than affected by it : be this as 
it may, there are always many who escape. In other words, how 
is it that many enjoy health with persons falling ill all around 
them ? — I need scarcely say that there must be some cause — I need 
scarcely say, that a man can no more be in health without cause, 
than he can be ill without cause. And yet, traism as it may 
appear, I incline to believe that the most important investigations 
must take their rise in the sustained conviction of this simple pro- 
position. We have endeavoured, with what progress let the state 
of science declare, long enough to preserve health by enquiring 
into the proximate causes of disease ; let us now, at least, include 
in the investigation, an endeavour to relieve diseases through a 
more precise investigation of the causes of health. Let us, in fact, 
apply that mode of investigation to the whole body which John 
Hunter so successfully applied to certain parts of it. Let us try 
whether we cannot at least extend the character, which John 
Hunter was the first to impress on the primary investigations of sur- 
gical science, through every part of its application ; and try what 
the same enlarged mode of enquiry will produce in regard to 
achieving some progress in medical science, on which the further 
advance of surgery now depends. 

We are not, therefore, to confine onr observation of disorder- 



95 



ing agencies to those examples in which they prodnce disease. On 
the contrary, we shall often obtain more useful knowledge, if we 
begin by observing what happens where the body is subjected to 
their influence with impunity. 

We must, in feet, study the phenomena of what we cannot dis- 
tinguish from health, if we wish to understand what we cannot but 
regard as disease ; and, in studying healthy actions, not confine our- 
selves to the mode in which granulations, or pus, or any other form 
of matter, is generated, but extend our observations to the ascer- 
tainment of the condition of the different organs of this great ma- 
chine ; examine what the respiratory, circulating, digestive, and 
secreting systems are doing, and this hotli relatively and absolutely ; 
the contemporaneous condition of the nervous system, and every 
manifestation afforded by its superintending power, both that which 
we consider corporeal, as well as that which we regard as mental. 
Then, in diseased conditions, we should observe, not only what 
this or that organ, the disorder of which may be chiefly, or perhaps 
solely, manifest to us, is about, but the state of every other part 
within reach of investigation. If this mode be really followed, 
even as far as we are at present capable of doing, I feel certain 
that much clearer and more simple views of disease may be ob- 
tained than those usually in circulation. But these remarks are 
general : my object is to teach : I will therefore try to shew you 
how to set about the work in question. And, first, I think you may, 
as a basis, assume the following data : 

That the body contains, within itself, certain powers of preser- 
vation, of maintaining an equilibrium under a variety of disturbing 
influences ; that diseases, in all their diversified forms, are, in fact, 
but actions of this preservative power* ; and that the operation of 
the latter takes place, subject to certain laws of limitation, of which 

• There is no objection, in the abstract, to the assumption that any process of 
a living body has a tendency to preserve that body : the objection, if we examine 
it, arises from the fact, that many of the processes we actually see, end, practically, 
in the death of that body. Neither do I make the assumption permanently as 
such : I wish you to take it as a sort of temporary structure, subsequently to be 
withdrawn, unless it be supported. If, in fact, all diseases ended in preserving the 
body, the assumption would be undeniable, the rule absolute. Hence we must, to 
retain the assumption at all, either prove the rule absolute by the simple fact which 
T have mentioned, appealing to its invariable success, or by explaining the excep- 
tions. Now, as we cannot prove that diseases are successful, since they so often 
prove fatal, we must, to sustain the principle, rely on the success which we may be 
able to arrive at in the explanation of such exceptions. 



90 



our present knowledge enables us to form no very correct idea, 
many diseases beiug incurable perhaps only in consequence of our 
ignorance. The only essential limitation of preservative actions 
with which we are certainly acquainted is exerted by Time and a 
variety of violent agents, chemical or mechanical, which at once 
destroy the whole machine. Many diseases, indeed, appear at first - 
as so many instances of limitation to the powers of life ; but consi- 
deration shews us that the preservative force, like every other law, 
implies the presence of certain conditions, and that the absence of 
these conditions, and not the absence of the law, produced the ap- 
parent limitation of it. Tn almost all diseases which we accustom 
ourselves to think of as identical in their essential characters, we 
find a great number of persons who die, and a great number who 
recover. Now nothing can be clearer than that this simple fact 
involves a truth of great importance ; namely, that the deaths did 
not take place from any abstract fatality in what we regard as the 
disease, but from the absence of certain conditions, wdiatever they 
may have been, which were present in those who recovered ; and 
that the success of the attempt at preservation in the one case, and 
its fliilure in the other, was determined by these conditions. 

If, for example, two forces, in themselves identical, operate on 
two different bodies, and produce dissimilar effects, it necessarily 
follows that the difference in the effects cannot be due to the forces 
themselves, but must be referred to the objects on which they act. 
So, if unhealthy states of atmosphere, or any other causes, pro- 
duce extensive disease in auy population, and some recover, while 
others die, common sense shews that (by means of ordinary induc- 
tive reasoning) the different result must happen, not from any 
peculiarity in the common cause of the disease, but from the vari- 
ous conditions of body, no matter how characterized, in different 
individuals. I am the more desirous of impressing this on you, 
because, though apparently a truism, it is a matter of vast import- 
ance, as you will see hereafter*. 



* The various modifications of vital actions, presented in the inhabitants of 
different countries, seem calculated to throw considerable light on the causation of 
disease. Although the opportunities of investigating these points can he enjoyed 
but by comparatively few persons, yet it does not appear that even those which 
have occurred have been cultivated with the requisite attention. It seems probable 
that the treatment usually employed by our Continental n^ghbours, the French, 
would scarcely admit of successful imitation in this country ; that, in fact, until we 
know something more of the real causes of acute aifections, a more active treat- 



97 



Now, inasmuch as we are all daily subject to some disturbing 
influence or other, and yet, in the majority of us, the functions of 
life not only proceed apparently undisturbed, but in a manner con- 
sistent with health, comfort, and enjoyment, how is it that Life thus 
resists the various and violent impressions which are so constantly 
acting on our physical and moral constitution ? All this requires 
more sedulous attention than has been hitherto bestowed on it. 
The observation of the manner in which Nature's operations are 
carried on in the most trivial local diseases, has been most valuable 
to us. We are often enabled to conduct our treatment, to direct 
our vigilance, to prognosticate results, from the simple knowledge 
of Nature's proceedings in the most common injuries, as in lieal- 

ment will be necessary in this country than in France, where again, perhaps, the 
more active practice usually pursued in this country would be scarcely an improve- 
ment, if it were even admissible. The influences by which the actions of life are 
modified in different countries seem, so far as they are external, to be referable to 
climate and mode of living ; but we cannot say that moral influences may not have 
considerable share in the business. Those, also, whatever their nature, which 
confer nationality of character, may also confer characteristic types on the actions 
of disease. Another promising mode of enquiry, and which, indeed, may be 
regarded as a branch of the foregoing, consists in the parallel which might be 
drawn between the various modes of living adopted at various periods, in the same 
country, and the characteristic diseases of the respective periods. We know that 
certain forms of disease, at one time very common, become, at another, compara- 
tively rare, and vice versa. I cannot think that a sedulous cultivation of this sub- 
ject would be unfruitful. Variations in climate, carefully ascertained, compared 
with simultaneous improvements in cultivation, draining, &c. would probably form 
an important section in such enquiry. If, for example, we could connect any pre- 
vailing character of diseased action with general habits of luxury and refinement, 
it would strengthen many of our present views ; whilst the co-existence of peculiar 
modes of life might help us to a truer perception of the causation of particular 
diseases. An interesting example, in connection with the last-mentioned part of 
the subject, is the relation which chimney-sweeps' cancer bears to a particular 
calling ; and the closeness of the connection (which I shall again advert to in an- 
other place), though, as yet, it has not been well investigated, is further illustrated 
by the fact, that a disease, so common in London, where we burn scarcely any 
thing but coal, is scarcely known, if indeed it exist at all, in Paris, where they 
burn but little. But the consideration of moral and physical influences, on the en- 
larged scale glanced at in the foregoing observations, might very conceivably con- 
duct us to a far more elevated position, than the comparatively humble or limited 
objects with which we commenced such enquiry might lead us to imagine. Sup- 
posing, for example, that, in the extended search for facts (the ground-work of 
inductive philosophy), we were to discover that the diseases of animals in a state of 
nature were extremely few or rare — that they were produced by natural and un- 
avoidable agencies — that the preservative powers of the animal economy were 
almost invariably successful — that certain facts, referable to the mental constitu- 

H 



98 



ing wounds bj adhesion or granulation. If, then, so much benefit 
result from the observation of a single feature in her operations, 
may we not hope, as I have already hinted, for results still more 
important, when we observe the mode in which she so generally 
preserves that exquisite harmony in the system, which, without 
any assistance from without, and often in spite of considerable in- 
terference within, maintains, out of millions of beings subject to 
daily sources of disturbance, thousands in health for every one that 
is deprived of it ? 

No one can doubt that such organs as the stomach and liver, 
heart and kmgs, bowels, skin, and kidne}', are very important or- 
gans in the animal econoni}'. The announcement of such a 
truism excites a smile. But there is another fact, scarcely less fa- 
miliar ; that, of a vast number of persons whom we see every day, 
not only without suffering, but in the actual enjoyment of exist- 
ence, there are very few in whom all the organs, which I have 
mentioned as so important, are perfectly performing their functions. 

tion of these animals, although they rendered them suhject to certain disturbances 
of a moral kind, as love, anger, aversion, and such like, yet that the exercise of 
these forces, as they were under the influence of a blind instinct, could neither rea- 
sonably justify the idea of their abuse, nor were in practice found to be productive 
of disease— and, again, in another class of animals (man, for example), we found, 
first, a responsible volition, associated with his moral constitution, and, simultane- 
ously, a multitude of diseases, in which Nature, if unassisted, proved often, per- 
haps generally, unsuccessful — that these new forms of physical disturbance involved, 
either on the part of the individual or his parents, or both, infraction of laws 
referable to his moral attributes — and that if, however ignorant we might still be 
as to the whole chain of causation of such forms of physical disturbance, yet that, 
even in animrls, in which we could not naturally discover them, we found certain 
ty-pes of them produced when such animals were in a state of domestication, 
invoh-ing certain imitations, as it were, of these moral infractions — and, 
further, if we found that, in man, the best treatment of his diseases really involved 
a tracing back and connecting any number of links in the chain of moral aberra- 
tion — we should indeed come to a point in the path of enquiry, where every step 
opened to our intellectual foresight -^-iews of increasing truth and beauty, and 
which would possibly unfold to us, not very unreasonable anticipations, that medi- 
cine might one day be raised, through the path of legitimate induction, into a 
branch of moral rather than physical philosophy — raised, in fact, from the lowest 
condition as a science, to an elevation superior to most others. It would render, 
in short, that to which we restrict our notions of disease, a physical result of moral 
infraction ; and, in confining that practice of medicine which was really neces- 
sary to a reti'acing our steps, through the instrumentality of physical agencies, to 
the laws we had infringed, confer on it the lustre of a practical moralit)^ The 
philsophical reader will easily perceive that much of this note is far from hypo- 
thetical. 



99 



Now the observation of these truisms is trite enough. I apprehend 
the reconciliation of them has not excited much attention ; yet, if 
thej be facts, they must be reconcileable ; and the demonstration 
of their consistency must be important, because it must, from the 
very nature of the question, develop some part at least of the pro- 
cess by which Nature herself preserves us in health. 

Now a great deal of this is very beautiful ; it is very simple, 
and, what is more, it is intelligible by the most ordinary capacity, 
and, in a great measure, attainable by those who have not studied medi- 
dne as a profession. Usually our enquiry into the causation of 
disease commences only when the disorders of the system are ac- 
companied by some degree of suffering, and, for the most part, 
when they have produced absolute pain. 

We now find that either the organ to which pain is referred, or 
some other, has manifested irregularity of function for a consider- 
able period ; but we by no means necessarily discover how the dis- 
order, which may have been consequent on this irregularity, or 
which, at all events, has at length succeeded to it, has been post- 
poned. Could we do this, and I feel confident that a more accu- 
rate observation of those who are said to be in health would 
enable us to do it, I have no doubt that we should discover connec- 
tions between different organs in different individuals, producing 
more useful knowledge, in the treatment of disease, than has re- 
sulted from all the experiments on living animals that have ever 
been perpetrated — that the enquiry, by shewing us how the pro- 
cesses of Nature are modified by the idiosyncrasy of individuals, 
would not only unfold to us much of the difficulty by which our 
most cautious, and ordinarily most successful generalizations are 
attended, but that it would discover enough to convince even those 
who trust too exclusively to their external senses, of what appears 
(to such persons at least) inexplicable, if not untrue — I mean how 
the constitutional origin of local diseases (accidents excepted) is 
universal, notwithstanding that many local affections occur in per- 
sons who are said to be in good health. 

Having given some consideration to this subject, I will tell you 
what I have observed with regard to it, which will, at all events, 
illustrate what I mean, and teach you how I intend that you should 
conduct the enquiry. When I find a man sa\ing he is in good 
health, that is, that he is free from any kind of bodily suffering, and 
he tells me, the next minute, something which clearly demonstrates 
that some important organ is performing its function imperfectly, 

H 2 



100 



minute enquii y seldom fails to elicit the organ on the compensating 
influence of which his health has depended. One man will state 
that his bowels do not act above twice or thrice a week ; but that, 
he will say, is common with him. If the enquiry be directed to his 
skin he will reply that he is all right there ; that he " perspires 
gloriously that the least exertion induces perspiration; and that ' 
often, in the night, you might " wTing his night-shirt." Disordered 
biliary secretions, and the explanation of the continuance of such 
a state of things for some time, are, in many cases, demonstrable 
where the patient makes similar observations. Where the bowels 
have been habitually torpid, without derangement of the system, 
you will almost invariably detect that the skin or kidney, and 
sometimes both, have been manifestly doing more than their share 
of duty. This, too, is sometimes to be inferred from the quality, 
at others from the quantity, of their secretions, and most com- 
monly from both, presenting obvious departures from the healthy 
standard. Many persons, whose circulation is so irregular, that 
at length palpitations of the heart, or some other marked disturb- 
ance, induce them to seek advice, exhibit, on examination, evidence 
that they have laboured under irregular biliary function for some 
time, without any of the usual sufferings consequent on disorder of 
the liver. In these, however, you will scarcely ever fail to discover 
that the disturbance of the heart, and that of the liver, to which it 
appears in the individual case to have been secondary, have been 
relieved, either by profuse perspiration, by an increase of urinary 
discharge, or, in some cases, by temporary depressions of the ner- 
vous system, characterized by a much enfeebled condition of the 
general functions of the body. There are, also, what appear to be 
very sufficient reasons for believing that, in many cases, a great 
quantity of injurious, and perhaps even fseculent, matter is elimi- 
nated from the lungs, or perhaps even from the superior portion of 
the mucous passage leading to the alimentary canal, as the mouth, 
fauces, and oesophagus. The facts pointing to this conclusion are, 
first, the frequent exhalation with the breath of odours that expe- 
rience shews us to be as unnatural as they are offensive ; and, 
secondly, the combination of this circumstance with two others, 
apparently very inconsistent with each other, namely, a feeling of 
health on the one hand, and indisputable evidence that some organ 
is not performing its functions naturally on the other. 

I have known many examples of the kind above mentioned, 
and I have tried to discover how far fcetor of breath was connected 



101 



with this or that organ as to order of frequency ; but the difficult}' 
of the subject, and the extensive observation required, has not 
allowed me to arrive at any results of practical importance. It has 
appeared that peculiar foetor of breath is more frequently connected 
with disordered bowels or liver than with derangement of any 
other organs ; but I cannot assert anything confidently on this 
point. It is important to remember, that, in disordered conditions 
of the body, in which noxious matters may be exhaled with the 
breath, the same odour may characterize the exhalation where the 
organs affected appear to be different. We usually, also, attach a 
characteristic odour to the impregnation of the system by mercury ; 
but I have seen a number of cases in which the foetor exactly re- 
sembled that occasioned by the administration of mercury, but in 
which no mercury had been administered. 

It is said that, in some cases of suppression of the urinary 
secretion, the exhalations from the lungs afford, as well as the 
secretions of the skin, an urinous odour. The phenomena com- 
prehended under what is called vicarious secreticm, in which one 
organ undertakes the duty of another, as the breasts that of the 
uterus, are but instances of the compensating power to which I 
have alluded. I knew a gentleman who had an uninterrupted state 
of good health, the only exception to it being that he was a bad 
sleeper ; but his breath was always, in the highest degree, offensive, 
and such as would suggest to almost any one that something very 
injurious was in this way got rid of from his system. But that 
interchange of function, of which we shall find, as we proceed, 
abundant other illustrations, has certain limits to the operation by 
which it so beautifully preserves the health of the body, notwith- 
standing the imperfection of certain of its organs. One organ 
cannot perpetually discharge the functions of another. 

This unnatural state of things finally disturbs the whole animal 
economy ; and that very connection and consent of action between 
different parts, which contributed to dispose of noxious influences 
through the agency of different organs, now renders these very 
organs so many links of a chain for the extension of disease. Now 
there can be little doubt, that, in the removal of disease by arti- 
ficial modes of proceeding, it must be of great importance to ascer- 
tain in what way Nature has so long postponed its occurrence, even 
when important organs have not performed their functions per- 
fectly. The more you reflect on this subject, the more will you 



]02 



be inclined to the opinion that all diseases are to be regarded as 
certain processes of life, having for their object the safety of the 
individual. 

Nor is there any fear, as yon will see when I come to treat of 
practical matters, that, in our present state of knowledge, such a 
view will in any way interfere with the energy of our practice, 
much less that it will lead to inertness in our treatment. The 
practice to which it leads is not so much one which requires less 
hand, as one which requires more head. It does not diminish our 
forces, but it tends to increase them by giving them a proper direc- 
tion. It does not, for example, interfere with the most active treat- 
ment of inflammatory affections ; but it adjusts its value as a means 
of removing dangerous symptoms, and carries our views beyond 
the abridgment of those actions which are immediately threatening 
to life, to those principles on which depends the prevention of the 
recurrence of diseased action. Without this, the most successful 
removal of acute diseases often entails prospective derangements of 
the system ; which, if they do not destroy, at least seriously im- 
pair, the enjoyment of that life which, for the time, we may have 
preserved. In many cases, in the present state of our knowledge, 
we are obliged to take enormous quantities of blood, and to satu- 
rate the system with mercury. Now, is it reasonable to suppose 
that the abstraction of an enormous quantity of this highly elabo- 
rated fluid, and the simultaneous superinduction on the system of 
a mineral poison, are negative matters ? I say, is it reasonable, a 
priori, to think this ? If, however, you have any doubt on the 
subject, I promise you ample demonstration that the fact is far 
otherwise. For the moment, let the facts already published by 
others, and some by myself (and I shall hereafter cite many addi- 
tional ones of very conclusive character), answer the question. 
But to return. In regarding diseases as the operations of a power 
preservative in its tendency, the question naturally occurs, why 
Nature, when left to herself, is so frequently unsuccessful ? To 
answer this question perfectly, our knowledge of the operations of 
life should also be perfect ; and our assurance that we really do 
leave Nature to herself equally so. But the preservative tendency 
of Nature's proceedings — not to mention that they are daily suc- 
cessful in a great variety of diseases — may be inferred from this 
fact, that, just in proportion to our ability to remove impediments 
to her operations, so is our practice ; or, to speak more philosophi- 



103 



cally, so is her preservative power uniformly successful. I say 
uniformly, because, were it not so, our reasoning on disease would 
be apt to be very fallacious. 

We can arrive at no law except where we either can obtain 
uniformity of result, or consistently explain its absence* ; unless 
we observe these conditions, we shall be in danger of applying the 
law to phenomena to which it is inapplicable, or of considering the 
law inapplicable when it is still in operation. The truth is, that a 
very sim.ple view of the subject appears to explain very satis- 
factorily how the preservative powers of Nature, as manifested in 
disease, require assistance in their operations. That the preserva- 
tive power of the body may have been amply sufficient to protect 
it, under the influence of those disturbing causes to which it is 
naturally subjected, is perfectly consistent with the fact, that the 
same power may be wholly inefficient to the removal of disturb- 
ances, the result of luxury, intemperance, refinement, or immode- 
rate indulgence of the passions ; and the more, if these agencies 
act, as the)' most commonly do, in combination. 

We find, in fact, that, in savage life, diseases are few and sim- 
ple ; and while this, though generally true, will vary in its appli- 
cation to localities where natural causes render particular districts 
more or less healthy, still the general truth seems impregnable. 
Celsus, after stating that, amongst the ancients, Machaon and 
Podalirius chiefly attended to wounds, and that diseases were attri- 
buted to the anger of the Gods, adds, " verique simile est inter non 
multa auxilia adversse valetudinis, plerumque tam eneam bonam con- 
tigisse ob bonos mores, quos neque desidia, neque luxuria vitiarant." 

But the difficulties vv^hich impede the curative operations of 
Nature are not fully appreciated when we limirour views to the 



* It is a law of Nature that the particles of water do not resist the application 
of a certain degree of heat ; but that, at a definite temperature, they separate, 
they no longer exist in the form of water, but are converted into steam. At the 
level of the sea, the temperature required for this (to make water boil, as we call it) 
is 212 degrees of Farenheit's thermometer ; but, on the top of a mountain, or in 
the receiver of an air-pump, partially deprived of air, they separate at a much 
lower temperature. Now the phenomena, as regards the quantity of heat, are 
very different ; but, as regards the water, the law is the same, the degree of heat 
required being regulated by the pressure of the atmosphere in the two cases. This 
is an illustration used by Mr. Combe (Constitution of Man) ; and I take this op- 
portunity of remarking, that there is great similarity in the mode of argument 
sometimes adopted in these lectures, although I had not read Mr. Combe's inte- 
resting work till long after they were written. 



104 



action of particular, as coutradistiugaished from tmly natural, 
causes, which immediately excite diseased action, or produce injury. 
We must also remember, that, when diseases become manifest, or 
local injuries call for repair, the body has often been a long time 
previously disordered by influences not less injurious, although, by 
reason of the compensating powers of which I have recently 
spoken, they are less cognizable ; so that the powers of life are not 
merely disturbed by the influences to which the art of man has 
subjected them ; but these forces, whatever may be their nature, 
are acting, at the period when disease becomes cognizable to us, on 
vital powers previously impaired. 

It is impossible to bestow any reflection on this subject, and not 
to perceive that death takes place, sometimes by a separate, and 
sometimes by a combined, operation of these influences. That is 
to say, that death sometimes takes place from the direct influence 
of a disturbing power ; as in severe mechanical injuries, wounds 
of organs essential to vitality, poisons, and the like ; at others, from 
causes in themselves not necessarily fatal, but which derive their 
fatality from the previously impaired machine on which they act. 
This happens, in a greater or less degree, in every epidemic ; in 
small-pox, in measles ; and, still more strikingly, in scratches and 
trivinl wounds, which sometimes produce erysipelas and death ; 
although, ordinarily, and on many previous occasions, in the very 
same individuals, the same injuries have happened repeatedly, 
without an}- ill consequence whatever. 

If the preceding views be correct, it necessarily follows, that, in 
the treatment of diseases, it will become a very important enquiry : 
what are those disordering influences which have occasioned any 
departure from the natural condition of the patient, previously to 
the disease which we are about to treat ? This enquiry will em- 
brace his mode of living not only at present, but at former periods ; 
the manner in which he may have been influenced by climate, &c. ; 
his temper, disposition; and sometimes even the constitutional 
pecuharities of his parents. In this way, we shall obtain some 
notion of the various disturbing influences to which he has been 
exposed ; and in some measure, also, of the impairment which 
they have produced on the vital powers, by ascertaining the kind 
of organization on which they have acted. In the absence of 
phenomena, demonstrative of the fact, these enquiries will also 
enable us to judge, with considerable accuracy, of the condition of 
the viscera, as having undergone organic alterations, or otherwise. 



105 



Now, all these enquiries are forced upon the physician ; or, at least, 
are obviously suggested by the very nature of the maladies for 
which he is consulted : but I am more particularly addressing sur- 
geons. The error consequent on the local disease, diverting the 
mind from the enquiry to which I have alluded, or very much cir- 
cumscribing the limits of such enquiry, is so common, that I am 
very anxious so to impress on you the utility of the above mode 
of investigation, that no authority shall induce you to neglect it, 
or underrate its necessity. There is no good treatment which has 
not reference to it ; and, even when the enquiry is not made, you 
will find that the sargeon has certain impressions which shew that 
he presumes, without enquiry, on what is, or what is not, the gene- 
ral force of the patient ; that he, in fact, acknowledges the impor- 
tance of the enquiry without having the industry to make it. I 
need not say that science can never be extended by such a cultiva- 
tion of it. There is no local disease which is not capable of 
affording instruction of the highest utility when properly con- 
sidered : but I cannot enter into all the processes of life now, with- 
out indefinitely postponing the practical matter with which they 
will be connected, and by which I hope to impress them on your 
memories. 

If civilization, by increasing the number of disordering in- 
fluences, has invaded the powers of Nature, it cannot be denied 
that it has also furnished some assistances ; which, imperfect 
though they may be, are yet in some measure to be regarded as 
compensations. These, as a whole, constitute the practical appli- 
cation of medical science. But, as it may be inferred from the 
foregoing, that the necessity for medical interference (accidents 
always excepted) arises from a diminution or a disturbance of the 
vital powders, itself the result of factitious causes, — so it necesarily 
follows that the application of the science w^ill mainly consist in 
measures calculated to place the oeconomy in a natural condition, 
not only as regards factitious causes of disturbance generally, but 
especially those which have influenced particular disorders. In 
effecting the object just alluded to, our attention will be chiefly 
directed to those portals of the body which are most exposed to 
injurious agencies, or through which they most readily obtain ad- 
mittance. All other things being equal, with regard to one or 
both of these conditions, our vigilance will next be directed to 
those parts which may possess, in a special manner, a power of 



106 



disordering the animal eeconomj. It is in this way that the air 
we breathe, and the food we swallow, become objects of such 
paramount importance in the treatment of all maladies. The phe- 
nomena of life, as unfolded to us in disease, shew clearly enough 
that the derangement of any part of the body is capable of dis- 
turbing the whole machine ; but they also force on us the convic- 
tion, that the general disturbance is excited more frequently by 
some parts than by others. If, however, their power of disturbing 
the system, abstractedly, were equal, still those which were most 
accessible to injurious impressions, or, at all events, most acted on 
by them, would practically become the chief objects of our care. 
Whether an organ derives its power of deranging the whole ani- 
mal economy from a greater influence, or by an equal influence 
more frequently brought into action, creates, practically, no 
distinction. 

I have thus endeavoured to connect, with the consideration of 
life, the necessity of the observance of its phenomena, and also to 
enunciate some of the fundamental principles on which your en- 
quiry should be conducted in their relation to diseases : to this 
enquiry I shall presently return ; but I will conclude this Dis- 
course, the chief object of which is to impress on you a clear per- 
ception of the following propositions : 

1 . The life of all things is, in a practical sense, to be regarded 
as the law under which they live, to whatever Idngdom of the 
creation they may belong. 

2. That an enquiry into the nature of that principle, whence 
such law^s emanate, can do little more than disabuse the mind 
from the influence of untenable hypotheses. 

3. That if we continue our enquiry, we can only hope for 
information from the study of phenomena ; and this, whilst it is 
promising in a speculative point of view, is the thing essential to 
professional purposes. 

4. That these phenomena should embrace those which attend 
health, as well as those which characterize disease ; and that there 
is no one source whence we may hope to derive more advantage 
in the treatment of disease, than from the investigation of that 
practical physiology, by which Nature shews the possible coexistence 
of health and comfort, with the functional derangement of important 
organs. 

5. That the investigation of life will embrace all causes of 



107 



disease, whether natural or factitious ; and their effects, not only 
in the organ on which they appear primarily to act, but on all 
others which may have become secondarily affected ; and that the 
cure of diseases will depend on the removal of the disturbing in- 
fluences, the surgeon being the negative. Nature the positive, 
agent in all. 

Lastly, I wish you to understand, that this kind of enquiry, 
whilst it wdll in time reduce operative surgery within narrow 
limits, will, so long as operations remain necessary, more directly 
influence our success in them than any other mode of investiga- 
tion whatever. Now, in furtherance of this enquiry, it will be 
necessary that I should consider the actions of life as unfolded to 
us in the phenomena of what are called the sympathies of the 
body, — and I may add, of the mind too ; — but this will be the 
subject of the next Discourse. 



108 



DISCOURSE III. 

ON THE SYMPATHIES OF THE BODY. 

The consideration of the living body is the object to which 
all our previous studies lead, and to which they are subservient. 
The only superiority that an anatomist and physiologist, however 
accomplished, has over a person ignorant of those sciences, is the 
superior power which he brings with him to aid his perception of 
the phenomena presented in the living body ; to assist his endea- 
vours to range such phenomena under the laws of which they are 
exemplifications ; and thus to advance his investigation of the 
causes which produce them. Hence it happens, that the observa- 
tion of a living being is not only that mode of enquiry in which all 
medical investigations must, by reason of ignorance of any other 
mode, of necessity have commenced, but in which the most cul- 
tivated kind of study must terminate ; it is really the Alpha and 
Omega of medical research. The various phenomena observable 
in the body, may be naturally ranged in two grand divisions : — • 
first, those which demonstrate the effects of various influences on 
the whole ceconomy, or on any part of it ; and, secondly, those 
which demonstrate certain connections, correspondence, or consent 
of action between its different parts. The phenomena constituting 
the latter class, are those which I propose td consider under the 
term Sympathy. 

As the phenomena of Sympathy are seen in all diseases, so 
they have, of course, been observed at all times ; and of this we 
find many interesting examples in the writings of Hippocrates. 
Indeed, you cannot peruse any medical work without finding ex- 
emplifications of them ; nor can we say that the observation of 
them has not been applied to the treatment of disease, since some 
of the most ancient remedies owe their efficacy to the sympathy 
between different parts of the body : but that sedulous attention to 
the phenomena of sympathy, which can alone render them fully 
available, as helps to investigation of disease, has only been begun 



109 



in modern times ; so that our knowledge in regard to them, may 
be said to be in its infancy. 

Mr. Hunter, whom nothing important seems wholly to have 
escaped, was probably more strongly impressed with the import- 
ance of what might be deduced from the consideration of the 
sympathies, than any other author : though Dr. Whytt has shewn 
that he was well aware of their importance. Subsequent writers, 
and particularly Dr. Wilson of Kelso, have made some useful 
applications of the phenomena of what he calls morbid sympathies, 
in the treatment of fever, rheumatism, gout, and other important 
affections. Dr. Wilson Phillip has also ably evinced his percep- 
tion of the practical influence of sympathetic phenomena. 

Mr. x\bernethy, however, deeply impressed with the enlarged 
and scientific views of Mr. Hunter, made the greatest step, in a 
practical sense, in the application of the sympathies of the body ; 
for his " Constitutional Origin of Local Diseases" was a beautiful 
and clear deduction from the " sympathy of the whole body with 
all its parts," as taught by Mr. Hunter. But we are hitherto far 
from having arrived at the full application of the phenomena of 
sympathy. Important as the use made of them by the gentlemen 
above mentioned may be, they are still susceptible of one much 
greater ; and there appears to be little doubt that we shall see, at 
no distant period, in what a prophetic spirit Mr. Hunter wrote, 
when he suggested that they might be made to contribute more to 
our knowledge of the treatment of disease, than any other subject 
whatever. 

I endeavoured to give a little impetus to this investigation in 
my " Remarks on the Unity of the Body," as deducible from its 
sympathies, and as applicable to the extension of the constitutional 
treatment of local disease ; and I shall here endeavour to enlarge 
on some points which were not so much insisted on in the work in 
question. Much certainly remains to be done, both in extending 
the application of the phenomena of sympathy to the treatment of 
diseases, in a manner not alluded to by the authors I have men- 
tioned ; and also in shewing how, and to what extent, they explain 
the importance of certain organs, particularly insisted on by Mr. 
Abernethy. In order to this, we must not content ourselves with 
merely looking to physiology, as arising out of anatomical inves- 
tigations, for information respecting these phenomena* ; we should 



* See Dr. Whytt's Works. 



110 

rather enquire whether they be not more calculated to reflect some 
light on physiology. 

In fact, the phenomena of sympathy are practical examples of 
function, and. their study is a practical physiology. No subject is 
more important than this ; and, inasmuch as no disease fails to 
present some illustrations of it, it is one, the whole of which it 
would be impossible to place before you in a general or elementary 
view. Hence it is the more necessary, that such a ^dew as is 
practicable, should be clear, simple, and limited to facts and con- 
clusions, which are, as much as possible, obvious and undeniable. 
If, therefore, notwithstanding that I restrict mj^self, for the most 
part, to such considerations, I should, in endeavouring to improve 
this path of investigation, express opinions, which though, as I 
trust, well supported, may not be obvious or unavoidable deduc- 
tions from facts, I can only entreat you to accept them as such, 
and to consider, and test their truth, before you adopt or reject 
them. 

Now, to make any arrangement of the subject is very difficult, 
because our knowledge of it is incomplete ; and therefore, in the 
one I propose to adopt, there is, you will recollect, no other object 
than that of throwing the matter so far into some sort of order, as 
to facilitate your remembrance of the facts, and your subsequent 
application of them. I will at once tell you the plan proposed. 
Ha\'ing defined what I mean by sympathy, I shall commence with 
the consideration of the skin ; taking up next the mouth and 
fauces, I arrive at the bag into which the windpipe and oesophagus 
open in common. I shall then proceed with the oesophagus, sto- 
mach, and digestive organs, — those, in fact, \vhich make the blood ; — 
then with those which distribute it ; and, afterwards, to such parts 
to which it is distributed, as have not been included in the fore- 
going arrangement ; reserving for the last, the brain and spinal 
marrow. 

But neither in the phenomena, nor in their application, do I 
profess to give you more than the ground- work of the subject : the 
superstructure will only appear when we arrive at the consideration 
of indiviudal diseases, the nature of which it will help you to 
understand. 

In order to convey to you w^hat is intended by the actions of 
sympathy, as distinguished from ordinary, and, as is usually 
thought, more intelligible nervous action, I would put the follow- 
ing case. When I press on the ulnar nerve, where it passes 



Ill 



between the point of the elbow (the olecranon) and the bony pro- 
jection on the inner side of it (the inner condyle of the hnmerns), 
I feel a sensation in the little finger and the one next it, very 
similar to that given by a slight shock of electricity. This is the 
sensation familiarly known under the term of " striking the funny 
bone." Now we explain this by saying, that usually the impres- 
sions on nerves are referred to their extremities ; and as the ulnar 
nerve, the nerve in question, goes down the arm and supplies the 
two fingers which I have mentioned, so we say, that the impres- 
sion produced by that pressure at the elbow is referred to the 
distribution of the branches in the fingers. Now I beg you to 
remark one thing here, which is, that it is, after all, the connection 
of the nerve with the brain, which enables me to recognize the 
sensation in the fingers ; because, if the communication be cut off, 
that is, if the nerve be divided, then such sensations referred to its 
extremities do not take place : wherefore it is clear, that as there 
has been an impression conveyed from the elbow to the finger, 
producing action there, so is there a communication from the finger 
to the brain, giving me a recognition of it. Some entertain an 
idea that it is difficult to reconcile this communication with the 
fact, that when a man loses his foot, — for example, by amputation, 
— he will complain of sensations in the foot which has been thus 
removed from his body : and Mr. Hunter seems to have felt a diffi- 
culty of this kind when he referred it to the effect of habit in the 
brain. Now it appears to me, that a little quiet consideration of 
the laws and phenomena of the nervous system satisfactorily ex- 
plains the difficulty, whilst it renders the phenomena in question a 
very striking exemplification of the law which explains it. The law 
may be thus stated ; — all true, as contradistinguished from illusory, 
sensation, requires, as conditions, the coexistence of two things, 
which may exist singly, and which may be called impression and 
sensation. Impression may exist without sensation, and sensation 
without impression. In the former case no idea is conveyed to 
the sensoriura ; in the latter, the impression is illusory : and now 
for the illustrations, — and first for those most in point, —that is, 
when, as in the case of the man's foot, sensation takes place with- 
out impression, since it must be admitted, that the foot having 
been amputated, no impression could have been made on the nerves 
of it, occasioning the sensation referred to the toes. 

When I see Mr. A or Mr. B, my particular friends, it is true 
that their images are depicted on the retina of my eye, and that a 



1]2 



sensation takes place in my brain, recognizing sncli impression on 
my retina : but how do I see these gentlemen in a dream, when 
perhaps they are miles distant from me, and when, therefore, there 
can exist no image of them on my retina, yet the sensation in my 
brain is as vivid as in the former case ? There is, in fact, only 
this dilference — that it is illusory. It may give rise to various " 
feelings, like the true sensation, and may be apparently as really 
connected with all the other feelings of the dream, — -joy, for instance, 
or sorrow, or surprize, — as when real. It is, in fact, sensation with- 
out impression. 

The contrary may happen. I may be asleep with my eye-lids 
open ; or I may be in a state of torpor, from disease. The same 
friends may now stand before me, and their images may be now 
really depicted on my retina : yet I see them not. In neither 
case does the brain recognize the impression, which here exists 
without sensation, the union of the two being the essential thing 
to true perception. But, as regards the eye, a still more striking 
instance is shewn on occasions equally familiar. I am walking in 
the street, and my mind is entirely engaged in thinking over some 
matter of interest. 

I perhaps meet a familiar acquaintance ; my face is directed 
towards him ; yet 1 do not see him, though I am awake, and my 
mind active at the time. Every one must have met with examples 
of this occurrence in their own persons. 

Now, here again, there can be no doubt that the image is de- 
picted on the retina ; but the mind, being occupied, does not re- 
cognize such impression ; and a man stops you with " I thought 
you were going to cut me," or some such expression. But nume- 
rous illustrations may be drawn from other sources. The necessity 
of both impression and action to true sensation is shewn in what 
we call paying attention to impressions. If my mind be otherwise 
occupied, a conversation, which perhaps would be interesting 
enough, may take place without my hearing it, although it is cer- 
tain that the oscillations of the air are the same as if I did. My 
attention being roused, and the conversation continuing, I now 
hear it distinctly, and my brain receives impressions of which be- 
fore it took no cognizance. This necessity of impression and 
action, to correct sensation, is often of great service. If all im- 
pressions necessarily produced actions, I could not think in the 
streets, with my brain occupied by various noises ; still less could 
I trust my ear to discriminate one sound amongst a number of 



113 



others, the actual impression of the sound sought being, as it often 
happens, less than those from which it is to be discriminated. Nei- 
ther could I, on many other occasions, prevent a thousand sources 
of diversion of the mind, by surrounding objects, from that which 
it is desirous of particularly considering. The very use of the eye 
would be half destroyed if I had not the power of directing sensa- 
tion to whatever class of impressions on the retina I chose. Vi- 
sion would be nothing but confusion. 

If, in regard to the ear and nose, impression always produced 
sensation, how should we ever feel quiet in the noise of a city, or 
become so indifferent as we do to unpleasant odours ? We know 
that, if we sleep in a noisy room, at first our rest is disturbed ; but 
we often become, in a night or two, indifferent to the impression. 
This is remarkable on board ship, where the guns do not awake 
people. Then the various odours of shops, such as druggist's, or 
some where the impressions are really offensive, how soon they are 
lost to those accustomed to them. We have all experienced this 
in the dissecting room ; yet we have at all times the power of re ■ 
cognizing the odour, if we really endeavour to do so. 

Then, how often people have heard noises when there really 
have been none to hear. The sense of touch presents examples 
of the same kind, being affected, in many persons, by sensations 
which they have compared to those resulting from all kinds of 
physical impressions, when no such impressions have been ad- 
dressed to the organ. Whilst, therefore, sensation may exist with- 
out impression and impression without sensation, all experience 
proves, that correct perception depends on both in conjunction; 
and to argue that, on ordinary occasions, there is no communica- 
tion between the impression on the nerve in my hand, and the 
brain which enables me to recognize it, would be, to explain the 
nature of those sensations which give us a real knowledge of sur- 
rounding objects by those which we know to be illusory. 

Tortoises move after decapitation ; many other animals run, 
too, and pigeons have flown after the same operation ; all this being 
an exemplification of the action of muscles of ordinary volition ; 
but in what respect do these phenomena of a few seconds resemble 
the sustained exercise of volition ? Would any one argue that the 
muscles are hot voluntary, because decapitation, and other less 
violent impressions, such as the actions of disease, either abrogate 
their power, or produce phenomena not observable during the 
natural exercise of their functions ? The truth is, that these phe- 

I 



J 14 

nomena have none of the natural characters of volition, any more 
than the contraction of a member removed from the bodj has. 
Thej are as abortive in their character as the sensations I have 
already referred to as illusory. 

I believe it was Redi who entertained the idea that every part has, 
as it were, two brains, one at the cerebral end of the nerves, the other 
at their termination in the several parts, and that the function of 
the nerve w^as the communication of sensation between them. 
This has been conceived ; and, whether it be the truth or not, it 
seems certain that the functions of the cerebral and distal extremi- 
ties of nerves, and the filament connecting them, are each pecu- 
liar, although contributing to a general result. 

To return to the case of sensation in the finger, resulting fi'om 
an impression on the ulnar nerve — I may observe that it is an ex- 
ample of the reflex action mentioned by Mr. Hunter, as exempli- 
fied in the polj^us, illustrated also by Dr. Whytt, in his experi- 
ments on frogs, and more recently dwelt on by Dr. Marshall Hall. 
Inasmuch as it is seen every day in the living body, it required no 
experiments on animals for the establishment of its existence. 
The expression, " reflex action of nerve,' ' is, in itself, a confined 
one ; for, as in the case which I have mentioned, it seems merely 
to imply that sensation may travel either from the brain to the or- 
gan, or from the organ to the brain. The facts of sympathy, how- 
ever, shew that it may travel from any one organ to any other 
organ of the body ; nor is it material whether it goes by way of 
the brain or medulla spinalis. The fact I wish to impress is, that 
there is a communication. 

It will be seen that the practical application which I have 
already made of the doctrine of sympathy, in my " Remarks on 
the Unity of the Body," contains abundant exemplifications of 
this action of nerve without regard to its direction. 

I dip my finger into warm water, we will say of the tempera- 
ture of 1)6° ; I feel it warm and comfortable ; I am not sensible of 
any other phenomena ; I have no evidence that my brain is the 
organ by means of which I feel the temperature : I only know this 
fi'om what is above stated ; namely, that, if the nerve be d.ivided, 
that is, if the communication with the brain be cut off, I have not 
the sensation : but^ suppose I now dip the same finger into very 
hot water ; then, indeed, the phenomena are very different : I have 
a sense of heat and of pain ; but I persevere, and keep my finger 
in the water for a few seconds ; I now feel that there is general ex- 



115 



citemeut of the system ; the mind itself is disturbed ; I could not 
compel it to pursue its operations ; and my heart increases both in 
the number and frequency of its pulsations. Here the heat ap- 
plied to a distant part has disturbed my heart's actions ; but I find 
no such direct connection between them as that between the ulnar 
nerve and the little finger. 

There is the general connection of all the nerv^es with certain 
centres and with each other ; and thus the nerves of the heart and 
finger may be said to be connected ; but there is nothing more. 
Sympathies are, doubtless, communicated by the nerves ; and all 
the nerves are connected with all parts by their communications 
with the brain and spinal marrow, and with each other ; so that the 
general connection of all parts by sympathy, may be explained by 
the general connection of all parts by nerves. But, if we endea- 
vour to explain particular sympathies by a reference to their parti- 
cular connections by nerves, we find that anatomy affords us but 
little help ; for we find very quick and rapid sympathy both with 
and without any direct nervous communication. Dr. Whytt, how- 
ever, has dwelt sufficiently on this subject; and, as it is not mate- 
rial to my present object, I will not enlarge on it. 

In the instance above quoted, we content ourselves with the 
simple expression of a fact, by saying that the parts sympathize. 
The word "sympathy," however, must not be understood as ne- 
cessarily involving the notion of pain or suffering ; since many of 
the most important examples of sympathy are attended by no suf- 
fering at all. You are to extend its signification to the words con- 
nection, correspondence, or consent, between any two or more 
parts of the system. You will understand, then, that the primary 
object is to make a simple catalogue of plain, demonstrable, and 
undisputed facts. If all parts can sympathize with all parts, it is 
immaterial from what point we commence our consideration. We 
will begin with the skin. 

SKIN. 

The skin may be considered as one of the portals through 
which external impressions affect the body ; the consequent affec- 
tions of various parts constituting so many examples of its sympa- 
thies. The large surface of the organ gives it a still further inter- 
est in connection with sympathy ; since it not only sympathizes 

I 2 



IK) 

with other organs, bat its different parts sympathize with the whole 
surface. Hence impressions applied to a comparatively small por- 
tion of it may affect many other parts of the body ; which, were 
the impression confined to the part to which it is applied, would 
not so frequently happen. This sympathy, then, between the skin 
and its several parts may be first illustrated. A blast of cold air - 
blowing on a small district of the skin will frequently produce cold 
and shivering of the whole surface : and two things are here very 
remarkable ; namely, that the affection of the whole organ is more 
readily produced if the blast of air impinge on a small surface than 
on a large one, and if it be applied to the posterior part of the 
body rather than the anterior. Cold, applied to the feet, and still 
more frequently if combined with moisture, will produce chilliness 
of the skin generally. These phenomena are familiar in " catch- 
ing cold," as it is termed. Warmth, also, will frequently be dif- 
fused over the whole organ by communicating this impression to a 
part of it ; and, although this is perhaps most remarkable in rela- 
tion to the feet, yet it is by no means always essential that warmth 
should be applied there. The addition of clothing to other parts of 
the body will diffuse warmth over the whole ; as we find in many 
persons who change the body clothing at different seasons, but who 
wear the same on their feet both in winter and summer. Irritat- 
ing substances, applied to limited districts of the skin, often pro- 
duce irritation over the whole organ : this happens in manj^ per- 
sons to whom flannel or woollen garments prove irritating. The 
garment may be a flannel waistcoat or worsted stocking ; yet the 
irritation produced by either, in many cases, becomes general. The 
eruption produced by tartar-emetic ointment is by no means neces- 
sarily confined to the surface to which it is applied ; that substance 
sometimes producing pustules in very distant situations, and the 
eruption, in other instances, extending widely beyond the space 
over which the ointment was rubbed, and giving rise to very se- 
vere irritation. I recollect once putting a small plaster of tartar- 
emetic ointment to the perinseum, about one inch and a half in 
length, and perhaps three fourths of an inch in breadth. The 
patient was not in good condition at the time ; and I shall not rea- 
dily forget the severe irritation it produced. Pustules arose over a 
very large district, extending up the clefts between the thighs, dowur 
wards and laterally, towards the anus and buttocks, and followed by 
superficial ulcerations, which were exquisitely tender, extremely 
painful, and difficult to heal. In fact, the irritation and disturb- 



117 



ance were so great as to confine him to liis room for more than a 
fortnight. 

Blisters will occasionally produce shivering. Burns are well 
Imown to give rise occasionally to the same sensation ; and trou- 
blesome boils after blisters are of familiar occurrence. These, 
too, are often very remote from the situation of the blister. Mr. 
Hunter mentions the popular remedy of putting a cold key down 
the back for bleeding at the nose ; and it is well known that tliis 
application produces a sensation of cold, generally, over the sur- 
face. We all know the refreshing influence of a cool breeze on 
the face when we are oppressed by heat. A similar effect is pro- 
duced by putting on a pair of cool shoes, after walking, in hot 
weather. Now, the sympathy, of which these facts are examples, 
you will find, by and by, to be very important, and chiefly in 
consequence of the extensive sympathies of the skin with other 
parts, which we will next consider. 

It should, however, be premised, that impressions on certain 
districts of the skin often act sympathetically on organs without 
any interveniny affection of the wliole surface : on these I shall 
remark presently. 

Impressions on the skin, then, will affect the HEAD. Cold 
will produce torpor of the brain, or even apoplexy, deafness, 
affections of sight, abrogations of taste and smell, and headache. 

Cold, applied to the skin, will also produce inflammation of the 
throat and fauces: it will affect the stomach by feelings of sickness 
and oppression in that organ ; or, in other cases, the BOWELS, 
by costiveness or purging, and sometimes by the production of 
inflammation. The reciprocity* of these sympathies is also well 

* Sympathy is not always equally remarkable^ in a reciprocal sense, as 
Mr. Hunter has observed ; but we must be guarded in our conclusions on this point. 
There are really no two parts between which the sympathy is not reciprocal, 
although various circumstances interfere with the mode and degree of its demon- 
stration. In the example quoted by Mr. Hunter, and which is so familiar to 
surgeons, the sympathy manifested by the stomach is nausea or sickness ; so that 
it is a glaring one, and not to be overlooked : but the stomach often sympathizes 
very unequivocally with other organs, though without any such prominent manifes- 
tations. So the testis may sympathize with the stomach ; and that it does so is 
clearly enough demonstrated by Mr. Hunter himself, when he speaks of excitement 
in that gland relieved by remedies addressed to the former organ. This observation 
of Mr. Hunter, however, is further interesting, as shewing that the possibility o f 
influencing primarily affected organs by those secondarily affected had not escaped 
his notice altogether, although he does not appear to have prosecuted the enquiry — 
a principle hitherto by no means sufficiently considered, however abundant the 



118 



marked. Blows, or slight concussions of the head, produce pale- 
ness or rigors. Headache produces cold sensations on the skin. 
Various disagreeable impressions on the external senses — those of 
sight and taste, perhaps, most frequently — produce sensations of 
cold on the surface of the body, though individuals differ very 
much as to the external sense through which this is most readily 
excited. Almost every known disorder of the STOMACH affects 
the skin. The best examples (I mean the most familiar) are seen 
in the irregularity of its functions, in the alternations of heat and 
cold, in indigestion, and in the shivering which precedes, and the 
perspiration that either accompanies or follows, the act of vomiting. 
Our most powerful sudorifics, as antimony and ipecacuanha, effect 
their object by means of this sympathy. Certain states of stomach 
are attended by eruptions on the skin and sores about the mouth. 
Erythema is sometimes produced by eating muscles. Pain in the 
bowels will produce coldness or paleness, and rigors. Habitual 
costiveness also invariably has some effect on the skin. If the in- 
dividual be otherwise well, this may be evinced by profuse or easily 
excitable perspiration ; if the health suffer, by coldness of feet or 
skin generally, and partial circulation in the organ. Troublesome 
sores about the margin of the anus are frequent results from irrita- 
tion in the bowels and other parts of the alimentary canal. 

Cold, applied to the skin, will moreover affect the RESPIRA- 
TORY organs, causing inflammation of the lungs, and affections of 
the mucous membrane lining the TRACHEA, BRONCHI, and their 
ramifications, of the substance which connects these last parts, and of 
the membrane which covers the whole lung (the pleura). The cau- 
tion we habitually employ in guarding the chest, especially in those 
w^ho have a predisposition to disturbance in this part, are familiar 
recognitions of the connexion to which I am referring. Any de- 
pressing influence on the skin affects the action of the HEART. If 

empirical illustrations of it, and the extension of which it was my particular 
ohject to urge, in so much of the practical application of this subject as I ventured 
on in my " Remarks on the Unity of the Body." It is certainly in the highest 
degree interesting to contemplate the acute perception of John Hunter. Although 
I am by no means a servile follower of his, yet I cannot help seeing in his works 
much of the ground-work of almost every new suggestion of value. We have talked 
a gre-rit deal about him, it is true ; yet much remains to be done before we can be 
said to do him justice. Mr. Owen, in the Lectures he is now giving, is likely, I 
think, to do much towards it. He proceeds in a very calm, philosophical spirit, 
and, with unusual advantages at his command, promises, I think, to give mankind 
a more true and just idea of Mr. Hunter than they have hitherto possessed. 



119 



the influence be sustained, as in exposure to cold, or severe, as 
shivering, in burns or lacerations, the action of the heart becomes 
depressed. If, on the contrary, the influence on the skin be tempo- 
rarj, it produces reaction in the heart, as if to restore the equi- 
librium. 

So is the sympathy reciprocal, for all affections of the heart 
produce eff'ects on the skin. If the heart act violently, whether in 
health or disease, the skin is evidently affected, generally by pour- 
ing forth its secretion ; and, in some sudden disturbances of the 
heart, the almost instantaneous occurrence of profuse perspiration 
is very remarkable. Where violent actions of the heart are not 
productive of this effect, the skin feels hot and burning, as in fever. 
The sudden depression of the heart's action, by some of the pas- 
sions, and especially by fear, is usually attended by paleness of the 
skin. Cold, applied to the skin, will, in some persons, change the 
functions of the liver ; and excessive heat seems to have the same 
tendency, although, perhaps, in a different manner. Rheumatic 
affections, excited by cold, are very frequently attended by disorder 
of the liver ; and the diseases of hot climates strikingly exemplify 
the effect of high temperature on the biliary functions. The well ■ 
known tendency of easterly and north-easterly winds to produce 
these affections in persons subject to them, is well known. Of the 
spleen, we know but little ; but the striking phenomena seen in 
ague (the very leading features of which are the varying state of 
the skin presented in that complaint, and the curious aff'ection of 
the spleen which, in many cases, accompanies it) leave no doubt 
but that there is a very active sympathy between the skin and the 
spleen. 

Instances, shewing the reciprocal influence of the lungs on the 
skin, are very numerous and interesting. Any thing increasing 
their action tends to produce perspiration, as running, jumping, 
&c. The remarkable manner in which the skin sympathizes in 
disease with these organs is shewn in every affection of them ; 
but perhaps in none more than in the relief occasioned by perspi- 
ration in asthma, and in the endeavours of the skin to relieve the 
lungs in the profuse perspirations accompanying phthisis. Indeed, 
we may be said to breathe partly by the skin, since, like the lungs, 
it throws off a quantity of carbon. No organ more certainly 
affects the skin than the LIVER. I speak not of the shivering 
that accompanies its organic diseases ; but its functional disorder 
very certainly affects the skin. Many patients, labouring under 



120 



such disorder, complain of cold and chilliness ; and I have known 
them complain of a sensation as if the lower extremities were im- 
mersed in cold water. The pecuhar tint of the skin, in affections 
of the liver, may also be mentioned, though not perhaps falling 
necessaril}^ under the term sympathy, as we are now applying it. 
With reference to the spleen, I have nothing to add at present : the - 
remarks I have to offer respecting this viscus will occur in a sepa- 
rate section. 

The sympathy between the skin and the KIDNEY is very re- 
markable ; and in no one respect more than in that alternation of 
function which, during health, is known to characterize the two 
organs. When the skin exhales profusely, the kidney secretes but 
sparingly ; but, in cold weather, or when we pass from a warm to 
a cold temperature, the kidney secretes much more abundantly ; 
and in sudden changes of temperature, as from a warm to a cold 
atmosphere, with a quickness that is extremely remarkable. Many 
of the latter cases are, no doubt, examples of the sympathy between 
the skin and the bladder ; which organ, again, by a kind of con- 
sent with the kidney, is more easily excited in cold than in warm 
temperatures. The effect so often produced by blisters* on the 
skin, occasioning strangury, is a familiar example of the sympathy 
between these parts. Impressions produced by cold on the skin 
are well known to affect the external urinary passage, greatly in- 
creasing the difficulty of the transmission of the urine, which 
again is facilitated by warmth. It is true that the contrary some- 
times happens ; but, of course, this is no less an evidence of cor- 
respondence between the parts in question. 

The reciprocal sympathies of the kidney, bladder, and urethra, 
in all affections of these organs, produce very marked effects on the 
skin. The diseases of the kidney and bladder are, perhaps, more 
frequently attended by severe rigors and profuse perspirations than 
those of any other organ, the lungs only excepted. In many 
cases, where the affection is but slight, and confined to the urethra, 
they are still extremely remarkable. Both as regards their severity 
and their intermissions, they are frequently not distinguishable from 
such as occur in ague. Even passing a bougie, which shall pro- 
duce no pain, will, as surgeons well know, not unfrequently pro- 



* This is scarcely, perhaps, a safe illustration ; as there is very good reason 
for supposing that it may be produced, in many cases, by absorption, and there- 
fore explicable on grounds not meant to be included in the term sympathy. 



121 



dace a fit of ague. Irritation in this canal will also occasion 
ulcers on the skin in its vicinity — a circumstance which has formerly 
led to a vast deal of confusion and error. I have known a bougie 
produce a circle of sores in twenty-four hours ; while, on the other 
hand, that ulcers are healed by the passing of instruments, com- 
bined with other judicious treatment, is now well known. 

I have spoken already of the sympathy with the skin, shewn by 
the membrane covering the lungs (the pleura). The whole of the 
abdominal viscera receive, also, either a partial, but for the most 
part, a complete, investment from a membrane which we call the 
peritonoeum. An affection of the skin, I mean the depression con- 
sequent on cold, has often excited inflammation of this part ; and 
warm applications, either general, as the bath, or partial, as fomen- 
tations of the abdomen, are powerful subsidiary measures to its 
relief, however it may have arisen, whether from cold or any other 
cause. 

Affections of the peritonaeum, which produce also heat and 
excitement of the skin generally, and which, for the most part, have 
been preceded by sensations of an opposite character, also give rise 
to extreme tenderness of surface in many cases — I mean not of 
the peritonaeum, but the skin. I do not here allude to that tender- 
ness on pressure, in which the inflamed surface is influenced 
thereby, but to those perhaps less common instances, where the 
bed clothes, on the slightest touch, induce suffering. 

The tenderness of the skin over parts affected, or even where 
no inflammation exists, is not peculiar to affections of the peri- 
tonaeum. It occurs occasionally in those of the chest, liver, and 
other parts, though less remarkably. VYe know, also, that salutary 
impressions are conveyed in the same manner ; as we see in the 
good effects resulting from local measures ; such as bleeding, blis- 
tering, irritating applications, or frictions of the part. 

The painful affection of the lower bowel, sometimes consequent 
on the application of cold and moisture to the part, as in sitting on 
damp grass, seems allied to this kind of sympathy. Impressions 
on the skin, besides the sympathetic disturbance of particular 
parts, will sometimes derange the whole animal economy ; so that, 
instead of determining what function is wrong, we can find no one 
discharged rightly. This happens in various kinds and degrees of 
catarrh ; and especially where followed by fever. The particular 
mode in which impressions on the skin have so enlarged and fatal 
a range in the production of the diseases of our variable climate, I 



122 



have endeavoured to explain, and, as I believe, correctly, in the 
work on Sympathy, pubUshed in 1835*. 

The skin is affected by various states of mind ; of which, fear, 
anger, and shame, in occasioning paleness or blushing, constitute 
the most famiUar examples. Lastly, the condition of the skin is 
always reciprocally influenced by primary affections of the consti- - 
tution. This is remarkably the case in animals where the impor- 
tance of the skin is well known. A horse's condition is judged of 
greatly by this circumstance alone; and the influence of good 
grooming, which, in a medical sense, may be defined as consisting 
in cleanliness, with moderate excitement of the surface, is w^ell 
known to have scarcely less eff'ect on the condition of the animal 
than the food itself. 

If w^e observe animals in a state of nature, their cleanUness 
and their condition are at once perceived by examination of the 
softness, pliancy, elasticity, and yet good fitting of their skin. 

All animals are, by nature, cleanly. Some, to be sure, exhale 
offensive odours ; but I know of no animal that becomes dirty, as 
our domesticated ones sometimes do, unless it be diseased. These, 
and similar circumstances observable in animals, have at all times 
impressed the few ; but they have not much influenced the many. 
A friend of mine used to say, with more truth, perhaps, than good 
breeding, " Man, Sir, is the dirtiest animal I know." 

It is certainly true, that the important relations of the skin 
have not been attended to in the manner they ought to be ; nor 
the secretions of the organ, in different diseases, sufficiently ob- 
served. Neither is the habitual treatment of this organ calculated 
to keep it in a sound condition — a thing of great consequence in all 
climates, but which becomes especially so in those which are 
variable. Cleanliness is very much neglected ; and condition, still 
more so ; yet, if the skin be treated as common sense and the ob- 
servation of other animals seem to suggest, it would be repaid by 
feelings of health and comfort. Every day, the whole skin should 
be cleaned, the exhalations of yesterday removed, and the surface 
excited by friction, as in wiping it with a rough towel. Of course, 
various precautions, as to the temperature of the air and water, 
will be necessary in different people ; but with these, the effect will 
be good in all. That the skin should be diseased, or that organs 
should be affected by it so constantly in this climate, is not only 



* On the Unity of the Body, &c. 



123 



not to be wondered at ; but, when the habits of nine-tenths of the 
people are considered, for my own part, I am surprised at the skin 
being so healthy, and so little diseased as it is. How people exist, 
and with health, even under the various accumulations of secreted 
and excreted matters which we occasionally see, is certainly a 
problem, the solution of which is not easy ; and, indeed, much 
more complicated than persons would imagine who have not con- 
sidered it. The very curious products from the skin, of various 
colours, especially red and blue, and of odours of indescribable 
foetor and variety, but still very characteristic, demand much fuller 
investigation than has been bestowed on them. 



OF THE SYMPATHY BETWEEN THE SKIN AND SOME OTHER 
PARTS, AS MUSCLES, BONE, LIGAMENTS, FASCIAE, ETC. 

There is no point in connection with the skin which will not 
be, as well as other sympathetic phenomena, more particularly 
dwelt on in connection with particular subjects ; but there are 
some remaining remarks which it is necessary to make in this 
place, Many of these parts are affected by what Mr. Hunter 
called contiguous sympathy, though this contiguity is not, as will 
be seen, an essential circumstance. Influences directed to the skin 
will affect the muscles. We see this in contiguous parts, when a 
stiff neck is occasioned by sitting in a draught of cold air ; and we 
observe a more general effect, of a different kind, in shivering. 
The history of tetanus*, too, as modified by climate, and as influenced 
by applications to the skin, suggests another example of the sym- 
pathy between these parts. Tetanus has been cured by immer- 
sion in cold water, in hot countries, and by the application of snow 
in cold ones. The phenomena of rheumatism, as well as various 
other more fugitive pains in the bones and joints, from cold, are 
familiar illustrations, produced by influences on the skin ; and this 
may be from a general effect on the whole surface, or of that cover- 
ing a particular joint. In the latter case, it is often confined to 
the joint in question ; and, although the influence on the skin may 
be general, yet the local affection may be confined to one articula- 
tion. In regard to those sheets of fibrous membrane which bind 
down the muscles (technically called fasciae), I have mentioned, in 
my Remarks on the Sympathies," &c. a very marked case of 



* Locked jaw. 



124 



inflammation in the fascia of tlie tliighj in a boy, which was evi- 
dently excited by cold. 

Now all primary affections of tiiese parts produce also secon- 
dary effects on the skin. Various sensations of cold, even to shi- 
vering, are common attendants on sprains, contusions, or lacera- 
tions of any of the structures I have just mentioned. There are, " 
in such cases, other sympathetic disturbances ; but I am now con- 
fining myself to the skin, as reciprocally influenced by bones, 
ligaments, joints, &c. In relation to the sympathy which exists 
between the skin, and parts which appear to be further implicated, 
through the skin w^hich covers them, some few additional circum- 
stances m9.y be mentioned. The viscera of the chest and abdomen, 
and their membranous investments, are frequently excited into dis- 
eased actions by influences applied to the skin coiming them. A 
very good illustration of this is seen in the cases mentioned by 
Mr. Pott. Injuries of the scalp, producing inflammation of that 
part, have been very frequently followed by serious inflammation 
and suppuration of the membranes of the brain. Mr. Pott's 
motto to his book is indeed literally true — " Nullum vulnus ca- 
pitis contemnendum since very trivial injuries were frequently 
followed by such fatal results. The cases often promised to do 
well at the commencement ; but, after u little time, pain, stupor, 
delirium, &c. used to come on. These cases appear to have been 
common in Mr. Pott's time; whereas they are now so rare, that I 
believe many persons of considerable experience have not seen 
them. I have seen two or three of them, but some years since. 
I believe the fact is, that wounds of the scalp are now better 
attended to ; the patient is kept quiet ; his bowels are regulated, 
&c. ; and there is none of this sympathetic extension of disorder ; 
for, unquestionably, when disordering influences act on a part, their 
sympathetic extension may be often either restricted or prevented 
by all means calculated to tranquillize the system. Disturbance of 
the cerebral circulation will, on the other hand, produce erysipelas 
of the head, affording a good example of this kind of sympathy 
from the brain to the skin. 



DIGESTIVE ORGANS. 



In tracing the surface of the skin to the interior of the body, 
the next set of organs whose sympathies are to be illustrated, in 



125 



coiiformitj with the plan proposed, will be those engaged in the pre- 
paration and digestion of the food ; and, if we take these in their 
enlarged sense, they will embrace the teeth, salivary glands, oeso- 
phagus, and alimentary canal, with certain other viscera ; namely, 
the pancreas, liver, and spleen. With regard to the TEETH, 
much perhaps cannot be said ; yet their sympathies deserve some 
notice. People are apt to consider the teeth as extraneous bodies, 
because they cannot demonstrate their organization, and because 
they know not how to arrange the kind of vitality with which they 
are endowed, with certain preconceived notions respecting the ne- 
cessary characters of living parts. The phenomena of sympathy, 
how-ever, here, as in many other instances, shew clearly enough 
that which the eye cannot discover. The disorders of children 
during the development of these organs need only be mentioned, 
with a view of impressing this important and indisputable fact, 
that they are, in the majority of cases, controllable, and, in some, 
removeable altogether, by attention to the general system*. 

As children are often allowed to suffer very unnecessarily 
under dentition, I shall relate a case of this kind. A child, who 
had first of all a bilious attack, and, subsequently, fits on the ap- 
pearance of every tooth, had been treated by leeches and calomel, 
on each occasion, with apparent relief, but without prevention of 
the recurrence of the disease. I told the mother that dentition 
generally produced irritation of the system, but that it was, like 
other sj'mpathetic phenomena, very much aggravated, in almost 
every case, by the state of the general health ; and that, therefore, 
if great attention were paid to this, the fits would certainly, in my 
opinion, be mitigated ; that anything like a renewal of salivation 
would be unnecessary ; and that, possibly, they might not even 
return. I found, on enquiry, that the mother was admonished of 
the approach of the fits and cerebral disturbance, by the appear- 
ance of yellowness of skin and disorder of the biliary secretion. 
As the child had already taken mercury several times, in salivating 
doses, I w^as anxious to avoid the use of this mineral. I therefore 
directed a plan, which had for its ordinary objects the substitution 
of a very plain diet, and occasional aperients of rhubarb and 
ginger, to ensure secretions from the bowels. I further directed, 
that, on the occurrence of the premonitory symptoms, doses of this 



* Tt would be a subject well worthy of enquiry, whether animals in a state of 
aature suffered, and, if so, to what extent, in teething. 



powder, with the addition of a few grains of jalap, should be ad- 
ministered every three hours, until copious evacuations should 
have been produced. As the ladj described the child to be now 
in the state usually sacceeded by the fits, and as the child had a 
very yellow aspect, I ordered them to begin at once with the more 
active powder. This was therefore done, and it was very gratify- 
ing to see the result. The fact was, that the child had no recur- 
rence of the fits or cerebral congestion, although the treatment 
had been begun thus late, as it were. The action of the purgative 
produced biliary secretions ; as, under favourable circumstances, 
many aperients will do, which do not appear to act on the liver 
otherwise than sympathetically through the bowels — a very im- 
portant fact in many cases. I have mentioned this case especially, 
because the fits had been attended with cerebral disturbance; 
for which leeches and mercury, with a view to affect the system, 
had been given on two, if not three, previous occasions. This is 
now two or three years since, and the further progress of dentition 
has not been accompanied by any recurrence of the symptoms. 

The occurrence of toothache from cold, independent of any 
decay of teeth, is well known ; and it is also certain, that peculiar 
states of constitution predispose to toothache, also independent of 
any disease of these organs ; the most common example of which 
is, the toothache of pregnancy. Then toothache, when occurring 
from causes more local, such as decay, will exceedingly disturb the 
general system, as almost every one must have either felt or wit- 
nessed. They evince, also, very marked sympathies with the 
condition of the stomach ; but there is something in this wdiich is 
very obscure. Usually, a foul state of stomach is accompanied 
by foetor of the breath, sordes, and early decay of the teeth ; but 
there are exceptions to this, though the general connection is 
remarkable. The teeth also frequently become sources of irrita- 
tion to the surrounding parts, producing irritation of the gums, 
abscess, morbid growths, and sometimes even diseases of the 
bones, or antrum. Mr. Stanley, in his Lectures on Diseases of 
Bone, lately delivered at the College, shewed two or three speci- 
mens of disease, which appeared to have resulted from misplace- 
ment of teeth. The gums are parts of low vitality, but of high 
vascularity. They sympathize with various states of system ; the 
most familiarly known examples are, perhaps, the state seen in 
scurvy, and that arising from the abuse of mercury. Various 
other conditions of system are, however, attended by unhealthy 



127 



states of the giims ; nor is that peculiar condition of them, nor 
the foetor accompanied by it, which is generally caused by mer- 
cury, peculiar to that mineral, of which more hereafter. I have 
seen, also, a much increased growth of gum, (which is more or 
less so common), in very direct connection with derangement of 
the general health. The most remarkable example I ever saw, 
was in a girl about twelve or thirteen years of age, whom I vi- 
sited in consultation, in the country. Many of the teeth were so 
involved in the luxuriant growth of gum, that the points only 
were visible, and all had their crowns more or less covered. As 
usual, the gum was highly vascular, and much produced over the 
incisores. I only saw her once, and I recollect she took nitric 
acid and plain diet, with good eifect : but I do not know the result 
of the case. A species of it is very common, and, in general, as 
one would perhaps rather expect, sympathetic with disorder of the 
alimentary canal. This state of gum is often accompanied by a 
high degree of vascularity of the mouth, tongue, lips, and nose. 



SALIVARY GLANDS. 

The salivary glands are parts as little subject to disease, as 
perhaps any in the body. Alterations of structure in them are 
comparatively rare ; and it is from analogies of this kind, more 
distinctly observable in the parotid and submaxillary glands, that 
we infer the nature and functions of a gland that w^e have much 
less opportunity of observing — namely, the pancreas, or sweet- 
bread. We see, however, on various occasions, that the salivary 
glands evince a very remarkable sympathy with certain states of 
the system. The affection of them, in common with other parts, 
by mercury, is well-known ; and they frequently manifest a sym- 
pathetic recognition of any irritation about the mouth. This 
recognition is shewn in the manner most usual with these parts ; 
that is, by an instantaneous increase of their secretions, much in 
the same manner as the lachrymal gland is affected by any irritation 
applied to the eye. 

The sympathy of these glands with the stomach is very re- 
markable ; for as soon as food is about to be introduced into that 
organ, and that preparation of it in the mouth, to which the sali- 
vary glands contribute, rendered necessary, they pour forth their 



128 



secretion in great abundance ; and this may be observed in ani- 
mals. Horses sometimes have the parotid duct wounded, so that 
it opens on the face, and it is curious to see the fluid shoot forth 
the moment anything is offered to the animal to eat. Those who 
have dogs much about them, must have often observed the abun- 
dant secretion that takes place from the mouth, whilst these inter- 
esting animals are watching for some little contribution from their 
master's meal. This is what has been called " making the mouth 
w^ater." These sympathetic affections, however, are not always 
shewn merely by an increase of secretion. The congestion of the 
parotid gland, in the disease commonly called mumps, seems the 
result of certain atmospheric influences, acting on a susceptible 
condition of the constitution. The curious manner in which the 
testis is known to sympathize in many of these cases, is matter 
of common observation. Diseases more frequently occur in the 
neighbourhood, than in the substance, of the salivary glands. Ab- 
scesses and tumors are often seen to form in the vicinity of, and 
upon, the parotid gland* ; and, in the former, the irritation of the 
gland is frequently evinced by a considerable increase of secretion : 
there is often a copious dribbling of saliva in such cases. The 
back part of the mouth and throat have well-marked sympathies 
with the skin, as already mentioned, indicated in the sore throat 
of common catarrh. Inflammation and irritation of these parts, 
also frequently arise from irritation in the stomach and other parts 
of the alimentary canal : the most marked and unmixed example 
of which is a kind of erysipelatous inflammation of the tonsils 
and throatt, attended with pain and difficult deglutition ; but which 
does not usually go on to suppuration or ulceration. The other 
affections so common in these parts, as inflammation of the tonsils 
proceeding to suppuration, are more mixed cases, and usually ac- 
companied by demonstrable disorder of the digestive organs, and 
some impression on the skin, appearing to occur in conjunction. 

* I have this day (May 16, 1837) seen a case of enlarged parotid, with in- 
creased salivation, in a child. In this there is apparently an absorbent gland, 
lying upon the parotid, also enlarged. There is likewise a man, with abscess over 
the parotid, now in the Dispensary, evidencing the same fact. 

t On May 12, 1837, a man applied at the Dispensary, to the condition of 
whose throat I directed Mr. Leigh's attention, as a well-marked example of this 
kind. The man was ordered plain diet and aperients, and in four days the erysi- 
pelatous affection of the throat has disappeared. — May IG. 



129 



ALIMENTARY CANAL. 

In the Alimentary Canal we arrive at another very important 
portal of the body ; and one, the sympathies of which have an 
excitability and range of operation, more extensive, more constant, 
and more active in the direct and indirect causation and control of 
disease, than any other set of organs. It is easy to understand 
why channels most exposed to injurious influences should have 
the greatest aptitude to give alarm to the system ; since the pheno- 
mena by which these alarms are exemplified, either afford means 
for the expulsion of noxious agents, or exclude their further in- 
gress. Mr. Hunter seems to have thought the sympathies of the 
Stomach more extensive than those of any other organ ; bat this, 
perhaps, might be difficult of demonstration. That they are more 
exposed to injurious excitement is, I think, indisputable ; and 
whether their more frequent manifestation result from this cause, 
from an increase of sympathetic influence, or from both in con- 
junction, it is perhaps, in a practical point of view, not very ma- 
terial to determine. The facts are indisputable, and the conclusions 
to which they lead, plain and simple deductions from such facts, 
to any one who will give a moderate attention to the subject. 
The circumstance of the stomach so usually evincing its sympathy 
by nausea or sickness, phenomena of a nature particularly obvious 
and striking, forms such a contrast with the unobtrusive manner 
in which many other parts evince theirs, that this is perhaps cal- 
culated to lead us to over-rate its comparative sympathetic ex- 
citability. There is no fear, indeed, that we can over-rate this 
property in the stomach ; but an exclusive attention to it may 
sometimes narrow our views, and lead us to overlook other sym- 
pathies which are coexistent with it, and on which, in a given 
case, that of the stomach itself may depend. We might thus be 
often led to consider a chain of phenomena to result from a pri- 
mary affection of the stomach, in which the disturbance of that 
organ might be a secondary, or even tertiary, link. 

The sympathies of different parts of the ahmentary canal with 
each other, may be first noted. 

Indigestion will produce flatulent, purged, irritable, or costive 
conditions of the bowels : a very small particle of undigested 
matter will frequently disturb the whole canal ; and this disturb- 
ance may wholly cease on its dejection from the lower bowel. In 

K 



]30 



children, this is very remarkable ; but I have often seen it in the 
adult also. One of the most obstinate and threatening constipa- 
tions that I ever witnessed, appeared to depend on a portion of 
undigested aliment ; as the symptoms ceased on its discharge. 
Deranged conditions of the bowels will, on the other hand, when 
apparently primary, equally disturb the stomach ; producing nau- 
sea, sensations of weight, and, in short, exactly the same symptoms 
as occur in the stomach when primarily affected. 

The action of many purgative medicines, given by the stomach, 
seems to depend on the sympathy of the bowels with this organ. 
This, perhaps, is especially the case with those which combine 
portions of jalap, antimony, ipecacuanha, or croton oil ; for no- 
thing is more certain than that many aperient medicines induce 
action on the bowels before the substances themselves arrive at 
that part of the alimentary canal. For, in the first place, vomit- 
ing will be often followed by purging; although the medicine 
shall have been rejected. Then again, the action of all aperients 
is usually increased by any substances that produce a tendency to 
nausea, as antimony or ipecacuanha. I recollect a gentleman who 
was sharply purged by putting the cork from a bottle of croton oil 
to his tongue. Now we know that many substances have a peculiar 
influence on certain organs, let them be introduced how they may. 
Thus, ipecacuanha vomits ; senna, and many other drugs, affect 
the bowels ; savine and ergot the uterus, cantharides the bladder, 
and so on : but, that the action of the aperients I have first men- 
tioned, when introduced into the stomach, is not to be explained 
safely in this way, may be inferred from the fact, that if they are 
introduced directly into the bowels, a much larger quantity is 
usually required than when they are given by the stomach. The 
greater efficacy of smaller doses, given by the latter organ, seems 
then to depend on some sympathetic relation between the stomach 
and bowels, by which certain actions of the former, no matter of 
what kind, lead to certain actions in the latter, as is the case in the 
natural performance of their respective functions. Now, if we 
turn our attention to the bowels, we shall find that anything which 
produces a tranquil condition of them, will tranquillize, in many 
cases, the stomach also ; a very common example of which is often 
presented in the mere injection of warm water. When ipecacuanha, 
or opium, or any other substance which has marked effects on the 
stomach, is introduced into the bowels, it will, it is true, affect the 
stomach ; but, in regard to articles by which the stomach seems to 



131 



have di particular disposition to be affected, so far from larger doses of 
thein being necessary to produce the effect, when directed at once to 
the stomach, we find that much smaller ones only are necessary ; 
which is the contrary to what we have observed in regard to the 
bowels, as affected by remedies introduced into the stomach ; these 
appearing to derive increased force from the sympathy between the 
bow^els and this organ. 

I dwell a little on this sympathy from the stomach to the 
bowels, because I regard it as very important, in a manner to be 
hereafter more particularly applied. It opens to our view various 
means of affecting the bow^els through the stomach, not only by 
emplojing aperients in a different manner, but by rendering various 
medicines aperient which do not at all belong to this class of remedies. 

On the principle here hinted at, I have known the action of 
the low-er bowels induced by infusion of bark ; and, what is much 
to the purpose, an action so natural, as I never witnessed from any 
purgative w^hatever, or indeed to be distinguished in any w^ay from 
natural action. Since, however, I shall have occasion especially to 
revert to this operation on the lower bow^els, through their sym- 
pathies, I will not pursue the matter further just at present. Any 
obstruction of the bowels, inflammation of these parts, or hernia, 
either with or without it, will produce distressing sickness of sto- 
mach ; nor am I acquainted w^ith any affection of any portion of 
the alimentary canal which does not affect the w^hole. Of affec- 
tions of the alimentary canal, arising from influences primarily 
directed to that part which we term the duodenum, we have not 
such direct evidence as we have in relation to other parts of the 
tube ; but the sympathies of the liver and alimentary canal, be- 
sides many other less demonstrable conditions (in which, however, 
the functions of the duodenum seem much at fault), leave no rea- 
sonable doubt of the reciprocal sympathy of this part and the rest 
of the alimentary canal. 

The sympathies between the alimentary canal and HEAD, are 
very remarkable. The headache, so frequently occasioned by 
disorder of the stomach or costive bowels, and sometimes also by 
a too relaxed condition of these parts, is well known ; as are also 
noises in the ears, various affections of sight, as motes, flies, and 
other kinds of illusory vision, and nausea and other affections of 
the taste. I have known all that disorder of smell and taste which 
is so common in ordinary colds, proceed entirely from stomachic 
irritation. Blindness, from worms in the alimentary canal, is w^ell 

k2 



132 



known to have frequently occurred in children ; whilst convulsions 
and St. Vitus's dance, arising from alimentary irritation, shew how 
the muscular system may be affected by the same sources*. The 
determination of blood to the head, dependent on irritation of the 
stomach, and disorder of the bowels, whether occurring singly, or 
in conjunction, is perhaps one of the most frequent indirect causes ' 
of apoplexy: the sickness which so often accompanies it, is an 
evidence of this sympathy. 

On the other hand, blows on the head, which produce cerebral 
disturbance, are very commonly followed by vomiting, as is well 
known. This sickness is, most likely, very salutary, and probably 
enables the organ to resume its function much sooner than it 
otherw^ise would. 

I have met with two remarkable cases of concussion, in which 
the reaction, which almost invariably takes place when the patient 
revives, did not take place at all, and rendered the cases extremely 
puzzling, and productive of anxiety. Both patients recovered. 
Their detailed relation would occupy too much space here; besides, 
it is important that they should be mentioned hereafter, in teaching 
a difficult branch of surgery. I will here only state, that both 
patients received the injury with a full stomach ; that there was no 
vomiting ; that consciousness returned very slowly ; and that the 
pulse kept at the range of from forty to fifty for two or three 
weeks, when the very cautious administration of very mild and 
nutritious food restored the system in each case safely to its equi- 
librium. I will next proceed to consider the sympathy between 
the alimentary canal and the viscera of the chest, and first of the 
HEART, which often sympathizes in a very remarkable manner 
with the alimentary canal. 

I do not assert that all the sympathetic phenomena occur with- 
out the intervening sympathy of some other organ ; but we must 
be content, in this place, with remarking simultaneous disturbance 
of the organs in question. When we take a meal, we always find 
the action of the heart affected ; in health, the pulse is always 
stronger, and somewhat more frequent. In various disorders, the 



* Very recently I saw a case, in which the patient, a little girl, laboured under 
deep-seated pain in the eye, with defective vision, simulative of inflammatory dis- 
turbance of the retina ; the coexistence of alimentary irritation, however, evinced 
by the dejection of worms, led me to restrict the treatment to measures calculated 
to correct this symptom ; when the affection of the eye got well. 



133 



influence exerted on the heart hy taking food is manifested in dif- 
ferent modes, but always in a very unequivocal manner. We 
need only feel the pulse before and after eating, to be convinced of 
this sympathy. In disordered conditions, however, the pulse is 
rendered much more frequent, and much stronger than in health : 
sometimes it is more frequent w^ithout being stronger ; and in cases 
where the nervous system is much depressed, or where the indi- 
vidual is much fatigued, the heart will not beat more frequently 
after a meal ; but, on the contrary, a frequent, weak pulse, will be 
changed into one which is less frequent, but more strong and full. 

Stimuli, such as wine, brandy, camphor, ammonia, and so on, 
when taken into the stomach, immediately increase the action of 
the heart : but here again the effect is not always the same ; for 
sometimes they strengthen the pulse, and render it less frequent ; 
but this is never the case in health, for then all stimuli taken into the 
stomach increase the action of the heart both in power and 
frequency. 

Many substances, on the contrary, when taken into the stomach, 
depress^the heart's action ; as ipecacuanha, antimony, and narcotics, 
when given in moderately small doses ; and we often successfully 
avail ourselves of the knowledge of this fact, in cases where the 
object is to diminish the heart's action, as happens in many dis- 
eases, especially in inflammation. 

Sickness is always attended by sympathy of the heart ; and, 
for the most part, by a very marked depression of its power ; the 
pulse becoming much weaker, and usually much softer and more 
frequent. All this, though in ordinary cases less strikingly de- 
monstrated, is equally true with regard to the bowels. Costiveness 
of these organs is often indicated by the pulse in a very remark- 
able manner. The most characteristic pulse I know of, as con- 
nected with this state, is a hard, retiring, somewhat small and 
fre(juent pulse. It certainly varies in most of its characters ; but 
more or less hardness is scarcely ever absent. In inflammation of 
these organs the pulse is usually small and frequent previous to the 
adoption of treatment. But although the condition of the pulse 
is different in different cases, it is always more or less affected by 
costive bowels ; and purging also is known to be attended by 
similar indications of sympathy, generally by increased frequency 
of the pulse, with diminution of power. 

Serious injuries of the alimentary canal, as well as of all other 
vital organs, produce depression of the heairt's action. Besides^ 



134 



irritation in the alimentary canal will produce all kinds of irregu- 
larity in the function of the heart, the most marked instance of 
which is the occurrence of palpitation. Many persons have been 
thought to have disease of the heart from the frequency of palpita- 
tions ; which, however, have ceased on restoring tranquillity to the 
alimentary canal. I have seen several cases of this kind ; and - 
shall only caution you against too hasty a conclusion — against the 
danger into which you will be apt to fall, of referring a real disease 
of the heart to mere sympathetic derangement. Now this is a 
serious error : for, although many of the measures which will re- 
move palpitations dependent on alimentary irritation are equally 
applicable to diseases of the heart, yet this is not the case with 
all of them. That exercise, which is so universally good in the 
one case, is mischievous in the other ; and the diet that would be 
good in some cases of disordered alimentary canal is prejudicial in 
affections of the heart. Besides, your overlooking the disease 
would certainly deprive the patient of the advantage of many other 
cautions, regarding general tranquillity of mind and body ; more- 
over, your reputation would suffer. I mention this caution, because 
I have known a very distinguished individual commit the error in 
question. You will find, in the work of Dr. Wilson, of Kelso*, on 
" Morbid Sympathy," two cases of severe and dangerous af- 
fections of the heart, which were more relieved by attentions 
to the digestive organs than by any other means whatever : in the 
one case, by the discharge of disordered secretions from the bowels ; 
and, in another, by the same means, combined with the evacuation 
of acrid matter from the stomach, consequent on the exhibition of 
emetics. In cases of any kind, where the functions of the heart 
are seriously disturbed, all its sympathies, and especially those with 
the mind and with the digestive organs, are of the first conse- 
quence to be remembered. Life is here held by so uncertain a 
tenure, that any cause of disturbance may destroy it ; since the 
action of the heart cannot be suspended, in one case in a thousand, 
without life ceasing instantly. Now, if the alimentary canal or 
any other part produce sympathy in the heart, it must necessarily 
affect the LUNGS also ; for the lungs will not act without the 
heart, nor the heart without the lungs, as will be observed when I 
speak of their sympathy with each other ; but the stomach will 



* "Wilson, on Morbid Sympathy — Angina Pectoris, 



135 



affect the lungs in a manner which by no means renders it necessary 
that it should do so through the intervention of the heart. 

Of all cases which evidence the sympathy between the alimen- 
tary canal and the lungs, asthma is, perhaps, the most familiar and 
striking ; for, whatever may be the degree of tranquillity of which 
the case is susceptible, it is always best secured by a moderate and 
cautious diet, and attention to the functions of the bowels. In the 
distressing paroxysms of suffering, so common in this complaint, 
nothing appears so frequently a predisposing and (temperature ex- 
cepted) exciting cause, also, as disorder of the alimentary canal ; 
whilst, in different cases, emetics, aperients, or both, produce the 
most striking relief. Various coughs are proverbially known to 
arise from irritation in the stomach, as well as some severe forms 
of irritation, attended with copious secretion from the ramifications 
of the wind-pipe, in some cases closely resembling phthisis : but 
more of this when I speak of the liver. 

Affections of the lungs, too, will reciprocally affect the stomach, 
producing irritability of that organ of a most distressing kind. I 
recollect a very interesting girl, who died of confirmed phthisis, 
whose stomach for a long time resolutely rejected almost every- 
thing offered it ; so that, notwithstanding that very small portions 
of nutriment were retained from time to time, yet it seemed won- 
derful how she existed with so small a quantity of food. Dr. 
Wilson, of Kelso, mentions croup as arising from irritation in 
the alimentary canal ; and, although I have not seen enough of 
the disease to enable me to speak confidently on the subject, yet I 
am strongly inclined to believe that, in the vast majority of cases 
of this serious affection, the predisposing cause is to be found in 
the alimentary canal. The well-known good effect of emetics, 
when given early in this disease, seems to favour the view here 
taken. 



LIVER. 

The alimentary canal is connected with several viscera, which, 
though we know not their functions perfectly, we have sufficient 
reason to beheve are, in some degree, coadjutors to the general 
function of assimilation. Of these, the liver, of which I shall 
speak more fully by and by, is the most remarkable. 

The disorder of the liver consequent on derangement of the 



136 



stomach — the ahuost constant sympathy which this organ evinces 
in every form of indigestion, sometimes by deficient, at others by 
redundant or morbid, secretion — is well known. Disorder of the 
stomach seems a very essential irritant in the generation of diseases 
of the liver so common in hot climates ; and, when the liver has 
been once diseased, or when it retains any chronic form of disorder, 
no persons know better how soon it is excited into active disorder, 
by imprudence in diet, than those who labour under the malady. 
The sympathy, too, is very reciprocal ; for the irritability of the 
liver, in this state, excites a salutary caution by the susceptibility 
which it reflects on the stomach ; the latter organ frequently re- 
jecting many substances wrhich are of injurious influence on the 
liver, especially fatty, greasy, or oleaginous matters*. Irritable 
conditions of the liver are also greatly soothed by caution in diet ; 
and, when disposed to active disturbance, by emetics. Most per- 
sons who are bilious, as it is termed, are v^ell aware of this fact. 

The necessity, as well as the difficulty of keeping the bov^els 
regular, on account of the effect of costiveness on the liver, are 
well known ; vv^hilst the bow^els, if not supplied by a due discharge 
of bile, become invariably disordered, and generally costive. Still, 
it is true, that various disorders of the bow^els, which are either 
primary, or not distinguishably otherwise, affect the liver. Per- 
haps, however, an extended consideration of the subject may 
throw some doubt over the nature of many disorders of the bowels, 
which, at first sight, appear to be primary. Nevertheless, it is cer- 
tain that many affections of the bowels, not necessarily arising 
from disorder of the liver, do very evidently reflect disorder on 
that viscus ; so much so, that there is hardly any disease of the 
rectum, of which surgeons see so many cases, in which we do not 
find the liver evincing sympathetic disturbance. 

As I shall have again to speak of the liver, I shall not enlarge 
farther upon it at present ; and what I have to say of the spleen 



* I recollect a case of severe jaundice in a woman who was doing exceedingly 
well ; but who, without any apparent cause, had, on two occasions, a sudden re- 
lapse of all her symptoms. She had been forbidden to eat animal food ; and, on 
the second relapse, she enquired whether it was probable that a small piece of ham, 
actually not more than a moderate mouthful, could have been the occasion of the 
recurrence of her symptoms ? On her being told, somewhat doubtingly, that very 
small portions of offensive matter did sometimes produce considerable disturbance 
in deranged conditions of the stomach, she said, " I think it must be so ; for, on 
the first occasion, I had eaten precisely the same thing." 



137 



will form a separate section. Of the PANCREAS we know but 
little. It is, in structure, like the salivary glands ; and, like them, 
but seldom found diseased. Like them, also, it secretes an aqueous 
fluid, which it pours into the alimentary canal in the same situation 
as that in which the liver transmits the bile. A few cases of dis- 
ease, of a curious nature, have occurred in it, but without our 
being able to deduce any thing additional to the very little we know 
of its functions. An unusually firm condition of pancreas is not 
uncommon. I have seen many cases of it ; but pathologists have 
not been accustomed to regard this as disease. The sympathy of 
the alimentary canal with the URINARY ORGANS, must next 
be mentioned. 

The reciprocal sympathy between the urinary and genital and 
the alimentary organs is numerously and strikingly demonstrated 
in a vast variety of different diseases. A few examples may suf- 
fice to exemplify the connection. Various substances, taken into 
the stomach, very much increase, as every one knows, the secretion 
from the kidney. The accompanying phenomena are very inte- 
resting. Some matters seem to be separated by the kidney, as if 
they were injurious, very soon after having been taken into the 
stomach ; as balsam of copaiba, and asparagus, the odorous prin- 
ciples of which are detected in the urine very shortly after they 
are swallowed. The same thing happens, also, in the case of vari- 
ous salts ; but other substances produce a purer kind of sympathy, 
if I may so express it ; that is, one not referable to the disposition 
in the kidney to separate particular substances, which may be 
rather referred to a sympathy between this organ and the general 
system, or the blood. For example, alcohol, various aromatics, as 
cubebs or cayenne pepper, colchicum, and many other things, taken 
into the stomach, produce a quick sympathetic recognition of them 
by the Iddney ; and it is very important to recollect, that the evi- 
dence is often of a different, and even of a contrary, nature. Thus, 
several substances which will, in one state of system, increase the 
secretion of the kidney, will, in another, diminish it*. The same 
diversity of effect is also produced by abstinence and rest, or ex- 
tremely moderate diet. I mean that it may in one case diminish, 



* Alkalies and acids will, at different times, and in different cases, increase and 
diminish the urinary secretions. 



138 



and in another increase, the secretion. That very intractable dis- 
ease, Diabetes, is probably but an exemplification of the sympathj 
of the kidney with the digestive organs. We know little of this 
disease ; but it may be that we have not enquired concerning it in 
the right manner. The kidney has been constantly examined with 
a view to some alteration of structure ; but nothing available to 
the solution of the disease has been discovered. For my part, I 
should rather conclude that the kidney, instead of being diseased 
in diabetes, was perhaps one of the few organs that were sound ; 
that it was, in fact, throwing off matters injurious to the system ; 
and which were generated by the diseased actions of other organs. 
This is, I believe, the kind of view that is now pretty generally 
entertained*. We might, with just as much reason, in my view 
of the matter, look for disease of the skin in phthisis, because its 
secretions are sometimes so profuse, as for the cause of diabetes in 
the kidney. Organs which are diseased are not remarkable for 
the abundance of their secretions. The kidney also sympathizes 
very much with the bowels. If the bowels are costive, the urine 
is generally loaded ; this seems to be healthy sympathy ; but large 
quantities of pale urine are excreted by many nervous persons, 
with partial circulation, whose bowels are habitually costive. But, 
in costive bowels, you scarcely ever see the urine perfectly natural. 
All real affections of the kidney reciprocally affect the alimentary 
canal ; but the stomach more remarkably, perhaps, than the bowels. 
To my mind, the superior excitability of the sympathy be- 
tween the stomach and kidney, as compared with that between 
the bowels and kidney, is very beautiful. The stomach is, as I 
have observed, one of the portals of ingress to the body ; the 
kidney, one of its outlets. No sooner does the stomach receive 
certain matters which are to be voided by the kidney, than sym- 

* Drs. KoUo and D. Latham referred the disease to chylopoietic derangement. 
When we consider the relation in which the kidney stands to the animal economy, 
it is impossible to resist the suggestion, that its action in diabetes is a secondary 
process in the disease, to say nothing of the comparatively few cases in which any 
morbid condition of that viscus is found, except such as may be readily conceived 
to result from undue excitement of its excretory functions. Nevertheless, the 
kidney may, one would conceive, be primarily affected in certain cases ; so that 
probably there may be cases in which the disease is really in the organ. The 
facts, however, strongly point to this as the exception, and to the sympathetic dis- 
order as exhibitions of the rule. "Whatever view we take of it, however, the 
thirst, voracious appetite, emaciation, dry skin, and, in some cases, disease of the 
bowels, all equally demonstrate the sympathy between the urinary and digestive 
organs. 



139 



patliy, like an electric messenger, communicates with the excreting 
organ*. Indeed, when we consider the sympathies of the portals of 
the body, we cannot but be struck with the subserviency they have 
to the safety of the individual. Now, as the kidney and the other 
urinary organs have close sympathies with each other, hence it 
follows that the bladder and urethra partake of any sympathy 
manifested by the kidney f- Further, the bladder and urethra re- 
ciprocally excite sympathy on the part of the kidney and stomach. 
Almost all affections of the bladder or the urethra produce increased 
flow of urine ; but there are exceptions, some diseases seeming 
rather to diminish the secretion of the kidney in certain cases. Ir- 
ritation in the bladder from stone, or disorder of its mucous surface, 
or irritation in the urethra, as from passing a bougie, will produce 
sickness ; and the tranquil condition of the urinary organs, as pro- 
moted by a regular condition of bowels, is well known. The 
lower bowel or rectum has a particularly marked sympathy with 
the bladder and urethra ; disease or irritation in either part almost 
invariably producing more or less in the other. This happens in 
many cases where stricture of the rectum, contractions of the 
urethra, piles, &c. are combined, rendering it extremely difficult, 
and often impossible to trace the order of their occurrence. I do 
not think it necessary to dwell longer on this sympathy, because it 
must be more fully discussed in connection with the important 
affections of the urinary organs ; but I shall, in conclusion, remark, 
that the most torturing affections, with which humanity is visited, 
result from inattention to this sympathy. Gout, gravel, stone, dis- 
ease in the kidney, the various excruciating affections of the bladder, 
and diseases of the urethra, are generally the result of inattention 
to circumstances which might be avoided : and the indulgent father, 
who pampers his child in food, may rely on it that he is often sow- 
ing the seeds of torture. If it be true that the stomach and 



* On the other hand, if there be stone, gravel, inflammation, or irritation in 
the kidney, sickness of stomach is invariably produced. 

t In the irritable bladder, depending on irritation in the urethra, the sympathy 
between these organs and the stomach is often very remarkable. A patient shall, 
in the fore part of the day, be teazed by constant desire to pass water ; whereas, 
after dinner, he shall be enabled to wait hours without being again called on. The 
contrary condition also is very common. The application of these facts is of the 
first consequence in many of the most teazing forms of this complaint, which 
readily yield when we avail ourselves of the hint thus afforded, as will be detailed 
in the proper place. 



140 



alimeutary canal are made to digest and prepare the nutritious 
parts of food, and that the kidney, with its apparatus of bladder 
and urethra, is merel}' concerned in carrying off the rubbish, as it 
were, — and of these two facts there is no doubt, — it follows that 
if you put rubbish (that is, innutritions or noxious matter) into the 
alimentary canal, you in fact put it into the kidney. Surely any - 
person with three grains of understanding will immediately per- 
ceive how disorders of the alimentary canal produce gout, stone, 
&c. ; and how that education rather than repression of animal 
gratification, so daily seen in the management of children, must^ 
by heightening such pleasures, and rendering them matters of 
habit, lay, as I have said, the seeds of these cruel disorders. In 
short, if we extend our view of the defects of education, as regards 
the animal propensities, what do we see ? We behold the urinary 
organs placed between two deadly fires, kindled by their sympa- 
thies — the one, that coming from the kidney through its sympathies 
w^th organs most abused by habitual indulgence, the digestive 
organs ; and the other, that coming on the side of the bladder, by 
causes operating in the urethra : and what is the consequence ? 
That, where people do not die of diseases that cut life short before 
its time, there is not one in ten, perhaps, of those who reach nearer 
to the limit of human existence, but is either a sufferer from, or is 
finally carried off by, diseases of the urinary organs. 

I could mention cases out of number relating to this sympathy ; 
but it is, perhaps, unnecessary : your success in practice, how- 
ever, will be materially influenced by your knowledge of 
this sympathy. I have had many patients from the first sur- 
geons in England, who have failed in their treatment ; and yet 
the very same treatment, as the patient has often said, has been 
successful. The patient looks to medical or manual measures ; 
and these indeed have often, nay generally, been the same ; but 
there has been superadded to them diet, adapted, as far as I was 
able to do it, to the particular accompanying disorder in each case ; 
and it is almost always the alimentary canal, or some other viscus, 
with which it has a vivacious sympathy, that is thus affected ; but 
the kind and degree are not the same, perhaps, in any two cases. 
The sympathy of the alimentary canal with the kidney has been 
already mentioned ; but it is equally true as regards the bladder 
and urethra. The substances mentioned in connection with the 
above organ (the kidney) will produce sudden, and often disor- 
dered, actions in the bladder and urethra. Alcohol will, in many 



141 



persons, cause spasms of the urethra ; and opium will, in many in- 
stances, as quickly relieve tliem ; without, be it remarked, any 
affection of the whole system that is cognizable as the effect of 
opium. Neutral salts, alkalies, and acids, also produce effects on the 
bladder and urethra; but these are not so good examples, because 
they may be explained in another manner. I have known thirty 
drops of laudanum relieve the most distressing irritation in the 
urethra in five minutes ; and I have known an injection of warm 
water into the rectum produce the same effect. The sympathy of 
the stomach and bladder has been remarked by Celsus. In con- 
nection with the removal of stone from the bladder, he says — " ut 
non ignoremus * * * ♦ saepe affici stomachum cui cum vesica 
qusedam consortio est : exque eo fieri, ut neque retineatur cibus, 
neqae si quis retentus est concoquatur, neque corpus alatur." 

In connection with the urinary organs, I may add a remark or 
two with reference to the testis, as sympathetically affected by the 
digestive organs. Pain in the testis produces sickness ; and, 
though it is seldom that we observe irritation in the stomach pro- 
ducing reciprocal affections of the testis, yet, as Mr. Hunter ob- 
served, an inflamed testis may be salutarily influenced by emetics. 
Besides this, there are, however, certain irritable conditions of 
these glands which are materially influenced by the state of the 
digestive organs ; and the most severe case I ever saw was one in 
which a remarkable disease of the gland was contemporaneous with 
extreme and habitual disorder of stomach. The curious sympathy 
between the salivary glands (a part of the digestive ~ system) and 
the testis, which also seems most active in the contrary direction, 
should be remarked. 

Johannes Hunter dixit consortium inter testes et ventriculum re- 
ciprocum non esse. " Videmus" (inquit) " testem seepe ventriculum, 
ventriculum raro testem afficere," quod ex hernia humorali illustrat. 
Nihilominus memorandum quod per multos alios casus hoc consor- 
tium etiam manifestum est. Qui fit, rogamus, ut consuetudo inter 
sexus famem fere moveat. Unde oritur ista debilitas non modo 
viscerum chylopoieticorum, sed totius etiam corporis quae semper 
excessum veneris insequitur ? Unde istud consortium fere omni- 
um animalium commune, quod inter vim virilem, et functionum 
assimilantium potentiam, existere videmus ? Quandoquidem igitur 
ventriculi consortium fere nausea vomituve indicatur, ita verisimile 
est, hoc consortii signum, observationem ab aliis signis, minus 



142 



equidem obtmsis, sed eeqiie certis et valentibiis ad morborum 
tain generationem, quam curationem detraxerit. Multee affec. 
tiones partium genitalium chronicse, apta dieta, et alvo bene ordinata 
moderantur. His adjicendum quod struma ssepe testes afficit, 
morbus in quo viscera chylopoietica, indicia valetudinis nunquam 
reddunt. Denique ex hernia humorali (quod exemplum a Jo- - 
hanne Huntero ad demonstrandum cursum consortii a teste ad 
ventriculum citatum) hoc consortium, reciprocum esse constat. 
Quippe nihil hoc certius esse potest, quam quod inflammatio testis 
ventriculi nauseam movet ita (aliis remediis frustra adhibitis) 
nauseee vel vomitus superventus, frequenter inflammationem solvit. 

I differ with Mr. Hunter with respect to some of his deductions 
on the subject of sympathy ; but it is not my object to criticise 
what he has done on this subject. It is quite evident that he was 
fully aware of its importance ; and my object is to shew what is 
true and useful, and how it is so, and not to argue on what may be 
erroneous or doubtful. Thus, speaking of sympathies as similar or 
dissimilar, he thinks continuous sympathy is similar ; but surely 
the effects of a blister and the occurrence of boil, though in prin- 
ciple the same, appear very different. The manifestation of a sym- 
pathy does not, however, appear to be necessarily different in prin- 
ciple, because the obvious character of the indication is different. 
He says, for example, that sickness of stomach cannot produce 
sickness any where else. Granted : but^ if the stomach manifest 
its sympathy by sickness, the bowels by purging, the kidney by 
the secretion of more urine, and so on, these symptoms may not 
differ in principle, or in the law of which they are the emanation, 
although the peculiar mode of manifestation may be different in 
different organs. I do not assert that they are the same ; but 
making distinctions of similarity and dissimilarity, unless we can 
demonstrate that they are essentially different, seems rather to en- 
cumber the investigation. What w^e are interested in knowing, is, 
the more frequent mode of occurrence, and the law which regulates 
it ; and not whether they are similar or dissimilar. These seem 
terms too general to admit of proofs, much less of useful practical 
application. 

Again : Mr. Hunter remarks, " The stomach appears to have 
this connection (sympathy) with the body more than any other 
part." This is a doubtful proposition. The heart is primarily 
affected, without the stomach appearing to participate. Neverthe- 



143 



less, the stomach is very rarely affected independently of the heart ; 
and, if we could discriminate more nicely than we can do as to the 
different characters of the pulse, perhaps we should find that the 
stomach never sympathizes without the heart and arteries doing so 
also. 



DISCOURSE IV. 

PHENOMENA OF SYMPATHY CONTINUED — ALIMENTARY 
ORGANS AND UTERUS. 

Mr. Hunter has observed, that the part sympathizuig will some- 
times be more prominently affected than the part with which it 
sympathizes. This is very true in regard to any two organs what- 
ever, although it is much more frequently demonstrable in some 
cases than in others. It is, however, no where more important to 
recollect this fact than in relation to the sympathies which take 
place between the alimentary canal and the uterus ; nor are there 
any cases in which a judicious application of the phenomena of 
sympathy is of more practical value, since they will often enable us 
to relieve, and indeed remove, some of the most troublesome and 
annoying kinds of disorder, which are either too often unsuccess- 
fully treated by specifics, or left alone as out of the reach of science. 
By the former, I mean various irregularities of the menstrual func- 
tion, and leucorrhoea ; by the latter, irritability of stomach, and es- 
pecially that which is too often concluded to be the unavoidable 
attendant on pregnancy. I will illustrate this by a case or two. 
A woman, of fair complexion, about thirty-two years of age, with 
an exceedingly wan countenance and emaciated frame, applied to 
me for relief from a profuse leucorrhoea. She stated that she had 
married five years previously ; that, antecedently to her marriage, 
she had had uninterrupted health, but that, a few months after her 
marriage, she began to feel unwell, and a discharge occurred from 
the vagina, from which she had never since been entirely free, al- 
though it had varied in quantity. She was very much reduced, 
and her countenance had that pale, sickly hue, with a patch of red 
on either cheek, which made her look more like a patient in con- 
sumption than anything else. On examining her, however, I 
could not make out that she had any affection of the lungs ; but 
her bowels were always obstinately costive. I put her on a very 
plain, nutritious diet, told her to clothe warmly, and took measures 
for regulating her bowels. The latter, as in most cases of the kind, 
proved a difficult task ; but it w^as at length (as it may generally 



145 



be, if the true principles on which it should be attempted are ob- 
served) accomplished, when the lencorrhoea ceased. She also 
gained flesh, lost her peculiar, unhealthy aspect, and became per- 
fectly well. Now, if any one will consider well the few facts I 
have here stated, he will see that the case was very unpromising ; 
yet it is very valuable, and, in my mind, very clear as to its ra- 
tionale. Her bowels had been always costive. So long as the 
utems had nothing to do but to separate the menstrual fluid, it 
seems to have remained undisturbed ; but, when called upon to ex- 
ecute its higher functions, it showed its inability by disorder and 
irritation. The predisposing and the exciting cause were equally 
clear ; the correction of the bowels removed both. 

In some cases the digestive organs appear to be performing 
their functions so far well, that the patient is free from indisposi- 
tion ; yet, on her becoming pregnant, a most distressing irritability 
occurs in the stomach. There is, in many instances, almost con- 
stant nausea and sickness ; and the affection is either regarded as 
necessarily incidental, quoad that individual, to the pregnant condi- 
tion. Now I do not mean to say what proportion of these cases 
are relievable, or otherwise ; but this I do assert, that many of 
them do not depend on the sympathy, in the strict sense of the 
term, excited by the uterus, but upon this sympathy acting on 
organs previously, or at the time, in a state of disorder. That 
there is some condition of the system favouring this sympathetic 
disturbance, is clear, because the latter is by no means constant ; 
many women being entirely free from it ; and that it depends on 
disorder of the digestive organs, otherwise induced, I am well con- 
vinced. This disorder too, w^here it already exists, is very apt to 
be aggravated by the idea w^hich is generally entertained, that 
women admit of, if they do not absolutely require, a more full 
diet during the growth of the child in utero ; w^hich, where the 
digestive organs are already deranged, of course increases the 
mischief. Another fact w^orth observing is, that w^hen the child 
advances, and when, therefore, we may presume that hypernutrition 
may be advantageously disposed of, the sickness not unfrequently 
ceases. Be this as it may, I have seen cases in which sickness was 
habitual during utero -gestation ; and yet, where attention having 
been paid to the chylopoietic viscera, it has wholly ceased, inde- 
pendently of any other measures. A well-marked case occurred 
to me in a young woman, who had borne several children, and in 
whom tliis sickness had constantly been an attendant in pregnancy. 

L 



146 



Her tongue was very irritable, and the secretions from her bowels 
irregular and disordered. It was clear, also, that the biliary secre- 
tion was out of order. On the correction of these, the sickness 
w^holly ceased, by which, in former pregnancies, she had never 
failed to be more or less troubled, except at short intervals. My 
experience, in cases of this kind, is necessarily limited : but I hope 
my professional brethren, w^ho practise in this department, will 
excuse me if I press on them the consideration of the sympathy in 
question. Granting that, under the circumstances of the purest 
health, the stomach is excitable during pregnancy, is this the time 
for allowing that extension of the diet scale, which is so commonly 
the case as regards quantity in the management of pregnant wo- 
men ? Does not an irritable stomach require, under any circum- 
stances, every practicable avoidance of disorder ? and w^hy should 
w^e take exceptions, or be less vigilant, where it occurs from sym- 
pathy with the uterus ? Granting, for the sake of argument, that, 
caeteris paribus, a more generous diet may be expedient, still no 
nutriment can be obtained from food which excites nausea and 
sickness. If, too, this sympathy be disregarded, may it not react 
on the uterus ? I am firmly persuaded that it may ; and that, in 
this way, miscarriages have occurred from reflected sympathy on 
the uterus from the digestive organs. I have seen that w^hich con- 
vinces me, that, even where the child is not born till the full time, 
its strength and growth are materially influenced by the condition 
of the digestive organs of the mother during pregnancy, as charac- 
terized by irritation or tranquillity. Indeed, the whole phenomena 
of sympathy render it apparently monstrous, to suppose that the 
function of the uterus can be wholly uninfluenced by constant ir- 
ritability of stomach, merely because it may not have induced 
abortion. Many cases of deficient and difficult menstruation have 
fallen under my notice ; and the dependence of this state on 
disorder of the digestive organs, has been so frequent and well 
marked, that it appears to me to be the most frequent cause of 
these affections. In the Remarks on the Unity of the Body, I 
have mentioned a well-marked case, which I will not repeat farther 
than to say, that it had been treated by specifics and other mea- 
sures, under a very popular physician, without any success, but 
that it yielded to attention to the alimentary canal and skin, with- 
out any difficulty w^iatever ; and without the employment of any 
of those remedies usually exhibited with a view to influence the 
uterus specifically. I have met with these cases in patients who 



147 



have consulted me for other reasons. Not very long ago., a lady 
consulted me for a slight sprain of her hand. On seeing her, I 
told her that so trivial a cause would not have induced so much 
inconvenience (for the effort was a very slight one, and the weak- 
ness consequent on it was very great), if her health had been in 
good order, for that I perceived it was much otherwise. I found 
that she was well aware of this, and had had a great deal of advice 
before, without having derived therefrom any material benefit. 
Her tongue was foul, her appetite irregular, and she suffered much 
from pain in the head. What she most complained of, however, 
was the extreme suffering she endured at every return of the ca- 
tamenia ; in other respects she was regular, but thought that they 
were rather too abundant. I put her on a strictly plain diet; gave 
her occasional aperients to regulate her bowels, which were dis- 
posed to costiveness ; told her to take exercise, and put her feet in 
warm water at night. In a few weeks she lost all her symptoms, 
and the first return of the catamenia gave her no suffering at all ; 
nor did they on the second return ; after which, as she was per- 
fectly recovered, I saw no more of her. The sprain got well ; 
rest being the only measure adopted for its cure. 

But it is not merely in pregnancy, or in the various disorders 
of the menstrual discharge, that the sympathy between the uterus 
and alimentary canal is so strikingly manifested ; nor is it in these 
only, that measures directed to the alimentary canal procure relief. 
Various cases of hysteria seem better combated by attentions to 
the alimentary canal, than by any other method. I recollect a 
yoimg girl in the Dispensary, who laboured under a curious va- 
riety of symptoms : at one time they were very like stone in the 
bladder ; at another, they closely simulated stricture of the rectum. 
Examination, however, could discover no disease of these parts. 
Then she complained of severe pain shooting through the parts, 
from before backwards : at other times she had severe pains in the 
abdomen. The history of the case only shewed that she had been 
bred in the country ; that, subsequently, she removed with her 
parents to London ; and that, after she had been about a year in 
London, the symptoms commenced with sickness and fainting fits : 
the development of her local symptoms succeeded to these dis- 
turbances. In this case, various specifics w^ere tried in vain ; and, 
amongst others, at the recommendation of a friend, who had seen it 
successful in similar cases, the ergot of rye : but nothing seemed to 

L 2 



148 



do any good. Her sufferings were often extremely severe, so that 
she could not rise from bed for pain. Counter-irritants were ap- 
plied to the loins ; and I scarcely know any measure, which has 
any reputation in such cases, which was not, at one time or other, 
unsuccessfully tried. They were combined, too, with every possible 
caution in diet : but all failing, I at length advised her to take no 
medicine, except a weak solution of salts in mint-water and tinc- 
ture of lavender ; and this only when her bowels required assist- 
ance ; in other respects, to continue her plan of diet, and to take 
exercise. Under this plan she ultimately got well : but I cannot 
say whether it was in consequence of it, for she was very many 
months under treatment : however, I never saw any case of hys- 
teria where the patient suffered so much actual pain as in this case. 
I merely, therefore, state this brief summary of the facts as they 
occurred. Not the least curious disorders of the uterus, are those 
in which the symptoms so closely simulate pregnancy, as occasion- 
ally to have puzzled the most experienced accoucheurs. In the 
woman, whose case I have mentioned elsewhere*, there was a regu- 
lar increase of size for ten months ; sickness of a morning ; some 
little shew of the catamenia, but scanty and pale, remaining : she 
felt motions, which she said were like a " little bird ;" the os uteri 
was felt as high as the finger could reach ; the breasts were full 
and painful, and a little milk-like fluid oozed from the nipples ; 
collected in a glass, it appeared like poor milk, and threw down 
albumen when tested by nitric acid. She had pains in the loins 
and head, and her feet swelled occasional/y . The tumor of the ab- 
domen seemed ill-defined, and higher than the pregnant uterus, and 
imparted the feeling that it arose from the right hypochondrium ; 
although she stated, distinctly, that it began low down on the left 
side. This woman took some pills, under the direction of her 
ordinary medical attendant, after I had seen her, jArhich a-cted 
powerfully on her bowels ; when the tumor gradually disappeared, 
and she got quite well. I should state that she had been married ten 
years, and borne one child only, which was about eight years pre- 
vious to her present complaint. This sympathy is so well known, 
that I should not, in this place, have said so much about it, but 
with a view to impress its practical application in a more sedulous 
attention to the digestive organs, than I believe has ordinarily been 



* On the Unity of the Body, &c. 



149 



paid to them ; for altliougli it is undoubted, that in many cases 
where the digestive organs are sympathetically affected, they are, 
as in many cases of pregnancy, the first deranged ; yet the sym- 
pathy is often not manifested until some new action is set up 
in the uterus, as in the process in question, or when the manifesta- 
tions on the part of the uterus are not in a natural function, buf 
in some departure from it, as in disorders of the catamenial dis- 
charge. It is not always easily determined whether the uterus or 
the alimentary canal be primarily disordered; the reciprocal sym- 
pathy is the thing to be remembered ; of this the proofs might be 
indefinitely multiplied ; and the practical application of it consists 
in attention to the alimentary organs, to which we can direct tran- 
quillizmg influences, in cases where any direct appeal to the uterus 
is either in the highest degree uncertain, or altogether beyond our 
power. 



ALIMENTARY CANAL AND MEDULLA SPINALIS. 

I believe that the effects on the nervous system, sjTnpathetically 
induced by disorder of the alimentary canal are now well known, 
and admitted. That impressions, primarily addressed to the ner- 
vous system, will disorder the functions of assimilation, is equally a 
matter of daily demonstration. I shall have to speak a little more 
of this in connection with the mind. I am now desirous of consi- 
dering, especially, the sympathy which exists between the alimen- 
tary canal and the spinal marrow. 

That disorders of the alimentary canal will disturb the impor- 
tant functions of the spinal marrow, there can be no reasonable 
doubt, at I shall endeavour to explain ; and that diseases and in- 
juries of the spine affect the secretions from the alimentary canal, 
is well known. The latter circumstance is adverted to by Sir 
Benjamin Brodie, in a good practical paper on diseases and in- 
juries of the spine, read last year before the Royal Medical and 
Chirurgical Societ}'. 

Now it has already been mentioned, that cramp, St. Vitus's 
dance, and convulsions (all affections of voluntary muscles sup- 
plied with nerves from the spinal marrow), often proceed from 
irritation in the alimentary canal : and worms supply us with an 



150 



example so familiar, as to be as \;vell known to the public as to the 
profession*. 

Now, when we recollect that one of the functions of the spinal 
marrow is to regulate the actions of the voluntary muscles ; and 
that, in the above conditions, volition is for the moment destroyed ; 
the conviction that the medulla spinalis is affected in some way or - 
other, is unavoidable ; that the cause too is originally in the ali- 
mentary canal, is proved by the expulsion of the worms, and the 
correction of its other disorders. We may not be able to under- 
stand the destruction of volition any more than its exercise ; but 
we know that voluntary power is impaired ; we know that affections 
of the spinal marrow disturb its exercise ; and we know that these, 
when serious, destroy it altogether. 

I no^v beg you to consider that very curious and dreadful dis- 
ease, tetanus, or locked-jaw. Its essential character is a ^dolent 
action of voluntary muscles, altogether independently of the will of 
the patient. ^Yhen confined to the face and jaw, we call it tetanus, 
or locked-jaw ; when affecting the muscles in front of the body, em- 
prosthotonos ; when those of the back, opisthotonos. It is a very 
curious thing : a man receives probably a slight wound (such, per- 
haps, as he may often have received before without any material 
inconvenience), followed in a few da}'s by this terrible affection of 
the muscular system. Now you know that, for the most part, 
wounds produce no such consequences ; and, it is equally certain, 
that, in many cases, the patients have experienced this at former 
periods in their own persons. This is a very important point: for, 
from it, we deduce no less than this, that the woimd cannot have 
been the direct cause of the tetanus ; but that it has occasioned it 
through an influence which owed its disordering effect to some 
peculiar condition of the body on which it was exerted. What 
this peculiar condition may be, is one thing ; its existence, another : 
the latter is certain ; the former may or may not be ascertainable. 



* Dr. ^yhytt raentions two cases of com-ulsions from worms, which I refer to, as 
shewing, or rather impressing the fact, that worms only produce them by reasou 
of the irritation they create in the alimentary canal, in common with other causes. 
The patients were a boy and a girl, of about the same age ; and, in the boy, the 
same symptoms recurred with alimentary irritation, without any worms being 
present. People are often surprised that children, with the usual symptoms of 
worms, are found to have none ; not knowing that many, or, indeed, in certain 
cases, o.iii/ other sources of irritation will produce the same symptoms. 



151 



Now, visible changes are sometimes detected, in these cases, in 
the spinal marrow; but, besides that these changes are seldom 
found, the question still recurs, how happens it that these changes 
are produced by a kind of injury which is happening every day, 
without the production of any such phenomena ? We can, indeed, 
make out no connection between the character of the injury and 
the occurrence of locked jaw ; for, whilst it is true that locked- 
jaw occurs after amputations, lacerations, and other injuries of a 
violent nature, it occurs just as frequently from injuries of a slight 
and trivial kind. It is said, that wounds of tendinous parts are 
more apt to be followed by tetanus than any others. It may be 
doubted whether we can safely assume this : but I cannot enter into 
that question at present. One thing, indeed, we know, — that injuries 
of parts of low organization (whether by neglect on the infliction 
of the injury, or as the direct consequence of the injury, as in dis- 
locations, sprains, and so on) disturb the system more than injuries 
to many other parts ; and that sickness, a symptom affecting a very 
important alimentary organ, is a striking feature in such disturb- 
ance. If tetanus, then, result from any peculiar disposition of the 
spinal marrow, in regard to which the wound can only be con- 
sidered as the exciting cause, you can see at once that the very 
essence of the enquiry into the causes of tetanus consists in the 
ascertainment of all influences capable of altering, or in any way 
disturbing, the spinal marrow. 

Now, we know that disturbance of any part of the body is 
competent to disturb the whole nervous system ; a fortiori, there- 
fore, disturbance of any part may disturb any part of the nervous 
system. 

Then, again, we know that no organs disturb the nervous sys- 
tem more frequently than the alimentary organs* ; and, if they 



* In the cases of tetanus, many of which are related in the Medical Ohserva- 
tions and Enquiries, costive bowels occur almost without exception. The most 
successful treatment seems to have been the alternation of aperients and opiates ; 
which latter seem to produce an opposite state of the spinal marrow. Further, in a 
paper on the good effect of cold bathing in tetanus, in the sixth volume of the 
work just quoted, the very first case again was combined with costiveness ; and 
one of the first effects from the cold immersion was a natural stool. How strongly 
does all this point, together with the impressions on the skin which appear to pro- 
duce tetanus in hot climates, such as exposure to night dews, &c. (see again the 
volume already quoted), to the skin, bowels, and medulla spinalis, as the chief 
agents in the causation of this frightful malady. 



152 



disturb the whole oftener than any other organs, it is assuming very 
little to say, that they will, at least, as often disturb a part of the 
nervous system : in this case, the spinal marrow. 

In a child of my own, violent fits and convulsions were re- 
lieved, in a few moments, by the injection into the bowels of warm 
water, and the consequent evacuation of them. Considerations, , 
then, of cramps, convulsions, St. Vitus's dance, in connection with 
marked alimentary disorder, induce the conviction, that disorders 
of the alimentary canal may produce a very disturbed condition of 
the medulla spinalis ; and I am satisfied, that, through the inter- 
vention of this state, they become one class, at least, of the remote 
causes of tetanus. I shall have to describe this disease in another 
volume, when all the facts will be considered. In sympathy, I 
prefer the contemplation of the living human body to all other 
modes of investigation, supported, of course, by the requisite pre- 
liminary knowledge ; but those who like another mode of demon- 
stration I may refer to Dr. Whytt's experiments on frogs. I will 
mention one or two of them. He laid bare the muscles of the 
abdomen, in a living frog, and applied a solution of opium to them. 
In other cases, he injected a solution into the bowels : the frogs 
were first seized with paralysis of the lower extremities, suc- 
ceeded by universal torpor, and death. In other experiments, 
he first destroyed the spinal marrow, when the opium, so applied, 
no longer produced paralysis, although the heart continued to beat 
for some time. Dr. Whytt also injected a solution of opium into 
the rectum of dogs, with the effect of producing paralysis of the 
posterior extremities : yet, when one of these dogs was purged 
severely by a strong injection of salt and water, he gradually re- 
covered from the paralysis*. 



* Now here the observation of the common disease, worms, as establishing 
the sympathetic afifection of the spinal marrow, appears to me to be, in a practical 
sense, still the more valuable demonstration. I admit the force of the experiment ; 
but, in those cases, we have another animal, and, in the case of the frog, one of 
a very different order from ourselves ; whereas, in the other, we have the natural 
manifestation of the sympathy, in the very animal whose diseases it is our especial 
business to study. 

There was recently a boy in the Dispensary who voided worms both by the 
mouth and bowels. I gave Dr. Campbell a large tape- worm, which was ejected 
from the mouth. The patient got well by aloetic aperients. A few days since, 
he re-applied, in consequence of having been seized with fits of an epileptic kind ; 
and he complains of a gnawing sensation in his bowels." This patient again 
recovered by the same means ; but without any further appearance of worms. 



153 



There is no synipatlij with which a famiUarity will be more 
useful than that under consideration ; since it will lead you to dis- 
criminate, with more correctness than any single principle with 
which I am acquainted, a class of cases of all others most puzzling 
and important. I allude to those in which irritation of the spine, 
thus produced, simulates disease of the vertebral column : you 
must recollect, however, that the alimentary canal is seldom singly 
affected. Usually, long before we are consulted, the sympathies 
of various organs produce simultaneous disorder in the liver, ali- 
mentary canal, and other parts ; and we have to collect, from the 
history, which organ has been primarily affected ; but, fortunately, 
the laws of sympathy, although (as I shall hereafter more parti- 
cularly explain), they render the detection of the organ primarily 
affected a very desirable object, do not always, nor even fre- 
quently, render it an essential one. I shall now put some of this 
matter before you in a case or two. 



CASE I. 



I w^as consulted in the case of a lady who laboured under a 
great complexity of symptoms. The history she gave informed 
me that the first complaint for which she sought advice was a pain 
which was referred to the uterus ; but the same history afforded 
undoubted evidence that her biliary secretions were disordered 
antecedently to the complaint for which she first sought advice. 
Immediately previous to ray seeing her, an opinion had been given 
that she had a lumbar abscess ; and it was the circumstance of her 
medical attendant in ordinary differing from this opinion, which 
led to my being consulted. I found her with some tenderness in 
the region of the liver, the secretions of which were disordered. 
The catamenia were deficient ; and examination of the uterus dis- 
closed a tender condition of the os uteri on its left side. The 
rectum was extremely irritable : she suffered great pain in passing 
her motions ; and at other times also. Examination of this part 
shewed the sphincter to be very irritable ; and the bowel felt ex- 
tremely hot. The examination, also, though conducted with all 
possible gentleness, gave her acute suffering. No disease, however, 
was discoverable, except a few wart-like projections, as high as the 
finger could reach, and a certain plicated condition of the bowel, 
which is common ; the arteries, however, throbbed most vehe- 



154 



mentlj. She had considerable tenderness along the lower part of 
the spine ; and there were a fulness and tenderness in the upper 
and inner part of the left thigh. Continuing the examination, I 
found that she was also very tender about the course of both 
sciatic nerves and over the capsular ligament of the hip joint. 
I should mention that some of her advisers had referred her 
complaints to the uterus. Her bowels were disposed to cos- 
tiveness; her tongue whitish-yellow, and furred; and she had 
cramps in her lower extremities. A careful consideration of 
all the circumstances, and connecting them with impressions 
derived from other cases, induced me to pronounce an opinion, 
that she had no disease either of the spine or uterus ; that, in fact, 
the disorders of these parts consisted in a deranged state of their 
nervous sensibility, dependent on disorder of the chylopoietic 
viscera ; and, as it appeared to me, probably originating in the 
liver. She was treated on principles emanating from these con- 
siderations. Simultaneous appeals were made to the skin and the 
alimentary canal by warm water injections and the vapour-bath ; 
alterative medicines, containing small doses of mercury, with a 
view to solicit the liver, were combined with a very cautious, 
moderate, and plain diet ; and, towards the conclusion, she now 
and then took an aperient, to which a little of the vinum colcliici 
was added. I saw her but occasionally, as she was ordinarily 
under the care of another gentleman, whom I met now and then 
in consultation. She, however, got relieved from all her symptoms ; 
and I saw her, eight months after her recovery, looking and feeling 
well. She is unfavourably circumstanced as regards the observ- 
ance of exercise, and other means of a preventive nature, the 
necessity of which I endeavoured to impress on her ; but, with the 
exception of being obliged to pay more than common attention to 
keep her bowels regular, she is free from complaint. 



CASE II. 



A young lady, of a very nervous, delicate temperament, and 
fair skin, consulted me concerning a pain in the hip, which the most 
distinguished surgeon of the day had pronounced to be disease of 
the joint. I examined the hip very carefully, and also the general 
functions of the ])ody. Her health was exceedingly deranged ; 
her bowels disposed to be torpid^ and then acting very irritably ; 



155 



her digestion was impaired, and her tongue white, with a paucity of 
secretion, a line of frothy saliva being generally visible on either 
side of it. She was very excitable. She had pain in walking ; but 
this varied, walking very much better sometimes than she could at 
others. The pain was distinctly referred to the hip. She had also 
pain in the back, which prevented her from sitting up long toge- 
ther ; and, if I recollect rightly, she had some uneasiness referred 
to the knee also. There was, however, no tenderness on pressure 
on the front of the joint, nor any pain when the head of the fe- 
mur was struck against the acetabulum, by a blow on the sole of 
the foot, during extension of the limb. Although I had seen dis- 
ease of the hip without these latter symptoms, I could not arrive at 
the conclusion that her hip was diseased, taking all the circum- 
stances of the case into consideration. She had, on a former occa- 
sion, consulted me for an anomalous pain in the foot, accompanied 
by a blush of redness on the tarsus ; but this last yielded to mea- 
sures directed to her general health. As, subsequently to that pe- 
riod, however, she had been under the care of another gentleman 
for the disease now said to be in the hip, and, as I had seen an 
opinion in writing, given by the very eminent surgeon to whom T 
have alluded, that the disease was an affection of the hip, I declined, 
as I could not participate in this impression, undertaking the case, 
without a consultation with the surgeon in question. This, how- 
ever, she steadily declined ; but added, that I might consult with 
any other surgeon or surgeons I chose ; which I acceded to, she 
naming the surgeon, who was Mr. Abernethy. I begged Mr. 
Abernethy to examine the joint very carefully, which he did ; and, 
in the end, declared his opinion to be the same as my own ; 
namely, that the case was a disordered condition of the nerves of 
the limb, depending on the general state of her health and nervous 
system. An issue which had been made was allowed to heal. 
She was made to take exercise ; and her diet and her secretions 
were carefully attended to. I had much trouble with her stomach ; 
and her tongue remained for a long time with the irritable charac- 
ter I have mentioned. She ultimately, however, got perfectly well ; 
had a short relapse of her symptoms, but again recovered, and, so 
far as I have been able to learn, had no return of them, I may 
mention that, in both instances, her tongue changed its unhealthy 
appearance before her recovery, and, on the first occasion, under 
the use of small doses of dilute nitric acid. During the relapse, 
however, the nitric acid produced no benefit ; her recovery being 



156 



due to the regulation of lier diet and her secretions, with air and 
moderate exercise, fatigue being always avoided. That cases of 
this kind m-dy and do terminate in disease is very probable ; bat 
this only adds to their importance and interest ; whilst the true 
mode of causation of many of them is, T believe, generally/ an irri- 
table condition of the digestive organs, acting on the spinal marrow, _ 
which again disturbs other parts. I should observe that the opinion 
given by the eminent surgeon to whom I have alluded had led her 
to adopt the treatment which he recommended ; and it was only on 
her having pursued this treatment for two or three months, without 
benefit, that she again applied to me. 

I knew a young lady, who died, after having suffered, at inter- 
vals, for nine or ten years, wath what I verily believe to have been 
a disturbed state of digestive organs, acting functionally on the 
spinal marrow, which again re-acted on the general health. I 
saw her only in the last months of her life ; and I regret to say 
that she died at a distance from me, and under circumstances 
which rendered it impossible for me to procure, much less to wit- 
ness, an examination of her body. She had, however, very much 
the same state of health as the lady whose case I have just men- 
tioned, but with many aggravations. Her tongue was much drier, 
and at times more vascular ; but still its general characters were 
the same. Her countenance was yellow, her biliary secretions 
were much disordered, and her stools black. Catamenia absent, 
occurring at long periods, generally of about three months. Pain 
across the stomach and left side, and tenderness in the same situa- 
tion. Cold feet, and inability to walk more than a very short dis- 
tance. She had considerable tenderness about the last dorsal and 
first lumbar vertebrae; and, immediately in this situation, there 
appeared to be a slight projection. She had symptoms at one time 
which, they said, had been referred to disease of the chest, and 
which became renewed on the approach of winter. She had no- 
thing of this kind during the time I saw her. I attended her for 
some time ; and she certainly improved in strength and appear- 
ance : her secretions also became nearly, and at one time quite, 
natural ; but she removed to a distance from me at tliis time ; and, 
in a consultation with her family, I stated that I should be happy 
to see her when it was practicable ; but, in a case so serious, it was 
impossible that I could, at such a distance, and seeing her at such 
long intervals, charge myself with the responsibility of the result. 
Having experienced some benefit, as I have said, she ultimatel}' 



157 



sank ; the chief symptoms being a thoroughly deranged state of 
digestion, with a gradual depression of the vital powers. Now, al- 
though she had the condition of spine to which I have referred, it 
had existed without any alteration or amendment for three years ; 
there being no further appearance of projection, or any other 
alteration whatever. I have already stated that the amendment, 
under my care, was temporary ; but I have never ceased to 
think, that, had she been under constant surveillance, she might 
have recovered ; but to treat such a case without the opportunity 
of exercising due \'igilance over it, is out of the question. 

A great deal of interesting matter will be found, in connection 
with the brain and spinal marrow, simultaneous with disorder of 
the stomach, liver, and lungs, respectively, in the Gulstonian Lee- 
tures of Dr. W. Philip, especially the third lecture, in which the 
cases shew to me clearly that the disorder commenced in the vis- 
cera, and that the organic effects on the brain were secondary. 
I therefore do not literally agree in the conclusions which Dr. W. 
Philip appears to deduce ; but, practically, the difference is unim- 
portant. 

My advice w^as once asked concerning a lady who had a very 
curious set of symptoms, referred to the spinal marrow ; one of 
which was, that the most trivial pressure on the vertebral column 
produced the most excruciating suffering. A very eminent sur- 
geon, who had formerly attended her, not thinking this possible, 
had made the experiment, no doubt very much to his own regret, 
as he was fearfully convinced of its truth. IVJy opinion was merely 
asked once about the case : it was a long distance from town, and 
I only saw the patient on that single occasion ; but I recollect that 
her digestive organs were exceedingly deranged, and did not appear 
to me to have been attended to with that scrupulousness which was 
necessary. I gave it as my opinion that she would not recover ; 
and she died a few months afterwards. Her body was not exa- 
mined. 

Another case of affection of the spine occurred, wdth which I 
had nothing to do, but which I cannot but conceive very important. 
The lady in whom it appeared had scarcely moved off the sofa for 
years. IShe had had a great deal of the best advice which this 
town afforded ; and, when I saw her, she had long given up every 
idea of treatment. I was never myself consulted in this case ; 
but some friends at length advised her to consult a very eminent 
practitioner in the country, under whose care she became, in a few 



158 



months, perfectly well. Xow I know that she took some medi- 
cine, the nature of which I did not ascertain ; otherwise her treat- 
ment consisted of gradual exercise, first with support, and subse- 
quently without any ; her diet being very strictly regulated. 

I could mention many other facts pointing to the sympathy 
between the alimentary canal and the spinal marrow ; but I have - 
said enough to excite your attention to this important subject. I 
will, therefore, only quote one more case, and, with a short com- 
mentary, conclude this section. 

Mr. Leigh, assistant- surgeon to the Dispensary, mentioned to 
me a very well-marked case in connection with this subject. A 
young gentleman was affected by occasional spasms of the mus- 
cles of one side of his face, apparently affecting chiefly the zygo- 
matici and the rectus externus of the eye. He laboured under 
symptoms indicative of disordered liver and alimentary canal. 
Under treatment, he voided some worms : and this was foUowed 
by relief of the spasmodic affection. A similar result followed the 
relief of subsequent alimentary irritation, which, however, was in- 
dependent of the existence of worms. It appears, however, that 
the measures which were recommended for the continued tranquil- 
lity of the chylopoietic viscera have not been persevered in : and 
the result is, that he has now impeded volition, affecting, more or 
less, one side, so as to threaten, at no distant period, paralysis. 
Not the least important part of this case is the fact, that, pre^-ious 
to the influence wrought in his case, by the measures to which I 
have alluded, several of the reputed specifics for such affections 
had been tried in vain. 

Now, if disorders of the alimentary can il \vill thus induce de- 
rangement of ftmction in the spinal marrow, what reason is there 
that they should not produce disease of the vertebral column ? 
There are many reasons in. favour of the probability of their doing 
so ; and not one that I know of against such probability. We 
know that nothing is more common tlian for disease of structure to 
be preceded by disorder of function. We know, too, that there is 
a great disposition in parts, especially important parts, to transfer 
their irritation to structures in their neighbourhood of less im- 
portance ; in which relation the vertebrae stand with regard 
to the spinal marrow. We know, too, that limabar abscesses 
occur without necessarily being accompanied by any disease of the 
vertebrae. We also know that persons, both antecedently to, and 
contemporaneously with, such affections, ha\'e, almost invariably, 



159 



disorders of the alimentary canal, and some of tliem mesenteric 
disease besides. I cannot, at present, enter into tlie important 
practical application of these facts to a more refined and strict 
treatment, both as regards the spinal marrow and the alimentary 
canal ; but I am convinced that it admits of improvement. I 
here mention only so much as seems calculated to impress on you 
the existence and the importance of the sympathy in question. 1 
have thus concluded what I think it necessary to say in this place, 
as illustrating the sympathies of the alimentary canal. There is 
no affection of the body with which it does not sympathize ; nor 
any that it (the alimentary canal) does not produce, either by di= 
rect or indirect modes of causation. Something, however, I shall 
yet add, in connection with bones, muscles, cellular tissue, &c. un- 
der distinct sections ; and I now proceed to illustrate the sympa- 
tliies of certain organs co-operating in the grand functions of the 
alimentary canal, considered in respect to their sympathies with 
other parts ; those with the alimentary canal itself having l)een 
already, for purposes of illustration, sufficiently discussed. 



LIVER. 



Dr. Wilson Philip observes, in a paper published at the end of 
his Gulstonian Lectures, speaking of the insidious nature of affec- 
tions of the liver, and the frequent participation of this organ with 
general disorders of the system : " For more than twenty years, I 
have examined the state of the liver as constantly as that of the 
pulse, and often derived more important information from the for- 
mer than from the latter examination — a proof of the extent of 
the vital sympathies of this organ." I shall here quote Dr. Wilson 
Philip in reply to a remark made in reference to what I had ob- 
served, in my book on the sympathies, as impressing the argument 
of the "Unity of the Body" (Highley, 1835). In that book, I 
state that the liver is generally more or less affected in diseases of 
the lungs. A reviewer denies this fact. I am happy in being able 
to quote a gentleman of Dr. Wilson Philip's experience on a point 
which (notwithstanding that which I have had in morbid exa- 
minations), may probably be considered as falling more within the 
province of the physician. He says that there is a species of con- 
sumption which originates in derangement of the hver (of all its 
forms the most common in this country) ; and, after adding that it 



160 



is very remediable, and that he has seen it in families of which 
some of the members had fallen victims to pulmonary disease, 
where this organ had been overlooked, &c. he says, " To this 
sympathy thousands yearly fall a sacrifice in these kingdoms, all of 
whom might be saved by so easy a precaution that is, attention 
to the bihary disorders which precede or accompany the earlier sym- - 
ptoms of pulmonary disturbance. " Affections of the liver influ- 
ence the brain in a similar manner ; and disorders of the brain 
affect the liver more than any other distant organ." In relation to 
this sympathy, see a case mentioned in connection with the treat- 
ment of inflammation. 

The liver is the largest organ in the body ; yet its functions are 
very imperfectly known; and, although we must feel much in- 
debted to gentlemen who labour so industriously in explaining its 
minute structure, yet I am convinced that a more fruitful source of 
enquiry will be found in a careful observation of its phenomena in 
the living body. We know that there is a very marked sympathy 
between this organ and most others ; and, indeed, we cannot assert 
that there is any one disease in the body which is not more or less 
frequently influenced, either in its causation or its progress, by the 
state of the biliary function. 

When we C(msider the vast quantity of blood poured every se- 
cond from the liver into the heart, through the inferior vena cava, 
we must perceive that the heart will be readily influenced, at least 
by the quantity of blood coming from such an abundant fountain ; 
and, accordingly, we scarcely see any afi'ection of the liver in which 
the actions of the heart are not more or less affected. I knew a 
gentleman, whose case I have already mentioned, whose heart was 
for a long time in an exceedingly disturbed state, and in whom no- 
thing appeared to do so much good as a dose of calomel, unless, 
perchance, he lost, w^hich he sometimes did, a little blood from the 
hsemorrhoidal vessels. His liver was obviously disordered, and 
had been so long anterior to any affection of his heart. The fol- 
lowing case is one of interest : Mr. Thorne asked my advice with 
regard to a female who had vomited a very large quantity of blood. 
Mr. Thorne gave the following as the previous account of the case : 
"Mrs. G. of leucophlegmatic temperament, was attacked, about 
three o'clock in the morning of May 1, 1836, with heematemesis. 
I saw her about nine, A.M. and found that she had vomited from 
about a pint and a half to a quart of blood. The countenance 
was pale and anxious ; pulse about 100, small and powerless 



1(31 



" bowels rather costive, which were habitually so. I gave her an 
aperient effervescing mixture, which quieted the stomach until 
the next morning, when I was again summoned to her assist- 
ance. She had vomited about a quart of blood about half an 
hour before, and complained of nausea ; fearing that the vomit- 
ing would again recur. The bowels had been opened by the 
medicine : stools dark and foetid. On examination, I found a 
strong pulsation just below the epigastric region, which, from the 
large quantity of blood which had been discharged, led me to ima- 
gine that an aneurism had burst into the stomach. The catamenia 
were present at this time. There was some slight tenderness 
about the epigastrium ; but little or no pain in the stomach. I 
gave her small doses of the plumbi acetas and opium. The dis- 
charge of blood ceased during the day, but recurred the next 
morning to an appalling extent. The stomach was still very irri- 
table, occasionally throwing off large quantities of bile." It was 
at this time that I saw the case. I found that the heart was acting 
in a very disturbed manner ; but a careful examination of the epi- 
gastric and abdominal regions induced me to refer the pulsation to 
the aorta. There was tenderness across the epigastrium. The 
patient was very much reduced, and pale. I found that she had 
habitually very costive bowels, and occasional uneasiness, referred 
to the right side ; that her attack had been preceded by, and that 
she had been subject to, palpitations. I told Mr. Thorne that I 
was disposed to refer her symptoms to a congested state of the 
liver, probably of long standing ; that I referred the disturbance of 
the heart to the blood derived from this source ; and that, during 
its disturbed action, some vessel in the stomach, to which organ 
there might have been a sympathetic determination, was probably 
the source of the hsemorrhage ; that, in so reduced a condition, and 
under such circumstances, the prognosis was most unfavourable ; 
but that, if he concurred with me, I should act on the foregoing 
opinion, and limit our measures to acting directly, and by such 
modes of sympathy as we could command, on the liver ; having 
also a view to determine to the surface of the body. I therefore 
directed that nothing should be put into the stomach but five 
grains of calomel (to which I found Mr. Thorne added ten grains 
of the extract of rhubarb), and that this should be repeated every 
four or five hours, if she lived, or if the intention of procuring pro- 
fuse discharges of bile rendered it necessary. I also ordered, to 
maintain her powers, injections of gruel by the lower bowel, and, as 

M 



162 



she lay, the skin to be excited by a flesh brush. These measures 
were followed by a discharge from the bowels of very copious, 
dark- coloured evacuations. There was no return of the haemor- 
rhage ; the vomiting from this time ceased ; and she began to ga- 
ther strength rapidly. Mr. Thorne assured me, a short time since, 
that the patient remains quite well — May 1837. I saw Mr. 
Thorne yesterday. May 29 ; and, mentioning this case, he said it 
was pure blood ; that it separated into its serum and crassamen- 
tum ; and was not distinguishable from blood which had been 
drawn from an arm into a vessel. 

I met with another case, very similar to the foregoing, but still 
more complex, in which the disorder of the liver apparently had, 
for years, produced at intervals the most inveterate irregularity of 
the circulation. That the liver will induce sympathy of the heart 
in other ways is very probable ; and that disturbances, acting pri- 
marily on the heart, will produce disturbance of the liver, I am 
certain. One of the most diseased hearts I ever examined was in 
a patient whom I did not see during life, and in whom no disease 
of the heart had been suspected, but in whom the symptoms were 
for the most part referred to the liver, which, however, was nearly 
sound, whilst the heart had become much enlarged, and its whole 
structure changed. I shall have occasion to recur to this sympa- 
thy in connection with inflammation. 



LIVER AND HEAD. 

I recollect a case where this sympathy was very marked, and 
where the progress of the cerebral affection bore such a relation 
to a growing disorder of the liver, from neglect of prophylactic 
measures, that, if 1 wished for a case for the purpose of demonstra- 
tion, I could not have had a better. Years elapsed, during which 
the biliary disturbances were of the most obvious nature ; whilst 
the cerebral were only evinced by pain and confusion of ideas, 
both trivial and temporary. At last, the frequency of bilious at- 
tacks was greater ; the cerebral affection more striking aud less 
transient. Then, at last, one eye became amaurotic ; and, soon 
after this, the bilious attack was accompanied by a sort of epileptic 
fit. Finally, the patient died. Now, for many years, this case was 
extremely tractable ; nay, even after the loss of one eye, and the 
epileptic fit, it continued so, by means wholly directed to the liver ; 



163 



but nothing could induce the patient permanently to refrain from 
exposing himself to all sorts of exciting causes, both moral and 
physical. Reiteratecl attacks were always the consequence ; and, 
on this persistent disorder of function, structural disease was sub- 
sequently superinduced. Perhaps, however, it is not necessary to 
say more on a sympathy so well known ; but I may just allude to 
the almost constant co-existence of hepatic and cerebral disturb- 
ance in almost every variety of fever with which we are acquainted. 
With regard to the liver and spleen, the few remarks I have to offer 
will be included in the consideration of the sympathy of the latter 
organ. The sympathies of the liver and alimentary canal and 
skin have already been sufficiently spoken of under the respective 
sections. The sympathy between the liver and urinary organs has 
been dwelt on as much as T think at present necessary ; and the re- 
mainining structures, as sympathizing with the liver, will be re- 
marked on under their respective titles. I know of no sympathetic 
connection manifested by any of the chylopoietic viscera which is 
not manifested by them all, although not always equally well 
marked, because more strongly excited in some than in others. 
Nor is there any organ in the whole body whose general participa- 
tion in disease is more universal, more influential, more important, 
or more insidious or marked, than that of the liver ; at least there 
is no organ which combines these characters in such a degree. 



SPLEEN. 



We know little, if anything, of the functions or use of the 
spleen ; yet there are circumstances, besides what we might infer 
from analogy, which leave little doubt that its sympathies are im- 
portant. With regard to the experiments made on living animals, 
to determine the functions of the spleen, they prove nothing. Some 
animals died when deprived of their spleen ; some pined after a 
certain time ; some became fat, and then again pined ; and, lastly, 
others did not seem much the worse for the loss of the organ. To 
conclude, however, that this organ is of little use in the animal 
economy is by no means a safe inference from these facts ; since 
its loss may have been supplied by compensating functions. Such 
a conclusion would lead us into various errors. As well might we 
infer that the lungs were unnecessarily large, because many indivi- 
duals live with little inconvenience in whom it is certain that, for a 

M 2 



164 



long time, a portion of the lungs could not have performed its 
functions ; that one kidney is sufficient, because it is occasionally 
found adequate to effect the secretion of urine ; or that the liver is, 
in great part, unimportant, because we find, in many cases, so 
small a part of it able to secrete the bile. We know that the ova- 
ries may be removed without injury to life. Now suppose that we 
did not know the function of the ovary ; to how absurd a position 
would the foregoing mode of reasoning lead us ! However, I am 
not writing on physiology further than in the consideration of phe- 
nomena. 

The history of ague is, in all respects, very interesting, and es- 
pecially as regards the spleen. Of all intermittent forms of dis- 
ease, there is no one so remarkable as this common complaint ; 
and it is curious to observe that it is, in some way or other, con- 
nected with the spleen, the physical condition of which it has the 
peculiarity of altering in a greater degree than that of any other 
organ in the body. It is well known that the spleen becomes enor- 
mously enlarged in many cases of ague ; and it is also well known 
that the liver is frequently much affected in that complaint. 

I had recently some very interesting conversation respecting 
ague with Mr. Curwarden, who has seen a good deal of it in Essex. 
He says that the ague-cake, as it is popularly termed, or enlarged 
spleen, is not so common now, and that ague itself is much less 
frequent in the neighbourhood ; since, by the practice of boring, 
they have now generally obtained good water, which they had not 
formerly. He also says, that the enlarged spleen is most common, 
and, for the most part, restricted to those who have had either re- 
peated attacks of ague, or who have had the complaint, locally 
called "long ague," for a very long time. 

His experience does not lead him to think favourably of 
arsenic, as compared with other modes of treatment. Mercury is 
the remedy for enlargement of the spleen. He does not consider 
any previous measure, in all cases, necessary to the good effects of 
bark ; but he thinks that its efficacy is often rendered more quick 
and certain by the previous exhibition of aperients ; and especially 
by emetics. He could not, he said, connect any given degree of 
disorder as affecting the liver and spleen simultaneously. 

On the occasion on which Mr. Curwarden was so kind as to 
favour me with his sentiments on this subject, I also met Mr. 
Kemble, a gentleman who had seen much of the intermittents of 
hot climates in Bombay. He told me that the liver, as we all 



165 



know, is there raiicli affected ; and the spleen also. The latter 
organ is there frequently inflamed ; and abscesses are found in its 
substance. 

Now, these facts point to a very decided sympathy between the 
spleen and the liver ; and this, if there v^ere no more direct con- 
nection, links the spleen in the general order of sympathies. When 
we observe the large column of blood poured into the vena portae 
of the liver from the spleen*, we cannot shut our eyes to the possi- 
bility that the liver may be affected by the quantity of the blood 
derived from this source, and probably by its quality also. On 
the other hand, obstruction to the circulation in the liver must 
necessarily occasion turgescence in the vessels of the spleen. 

I have seen many cases, apparently proceeding from disorder 
of the liver, where I have thought it probable that the disorder 
might be in the spleen, notwithstanding that the relief was obtained 
by remedies directed to the liver ; and for this reason, that, 
although the biliary secretions have been manifestly disordered, 
and the countenance bilious, yet there has been pain, and even 
tenderness, in the region of the spleen. The curious, and, at pre- 
sent, inexplicable intermission of various disorders, must have 
some cause ; and the probability is, that the cause is much more 
simple than we, in our ignorance, are inclined to imagine. 

F or almost all disorders assume, at different times, a more or 
less intermittent form ; and it is curious, that, in general, the very 
same remedies are beneficial v/hich produce such decided relief in 
ague. On the other hand, persons who have suffered much from 
ague have an intermittent form given to every subsequent disorder 
under which they labour. Mr. Curwarden mentioned to me a 
case of cancer in the breast which had gone into ulceration, in a 
lady, in whom the paroxysms of suffering occurred regularly every 
third day. 

We know that urethral irritation will produce ague, especially 
in those who have resided in warm climates ; and, although I 
myself have never seen that remedy necessary from such a cause, 
yet Sir B. Brodie says, that quinine is very beneficial in its relief. 
Now all these considerations point, if not to some common cause, 
at least, to some common law in the economy ; and, could we un- 
derstand it, we might at once unravel a variety of obscure dis- 



* Hippocrates, in his aphorisms, recognizes a connection between the spleen 
and dysentery, and also with affections of the mind. 



166 



orders ; sncli as snvetalopia, hemeralopia*. and many others. I do 
not say that the veil which at present covers these affections will 
be raised by any investigation of the phenomena presented by the 
liver and spleen in various disorders ; bnt I am well enough in- 
clined to believe that they may be investigated with more chance 
of success than those of any other organs ; especially if we com- 
bine with the enquiry, a particular obsen'ance of any organs, the 
alterations in the physical conditions of which we have an oppor- 
timity of investigating ; which would, of course, embrace the ali- 
mentary canal, and, imder some circumstances, the lungs also. 
When I speak of the physical conditions of these organs, I mean 
as characterized by the kind or quantity of air or food to which 
they may have been subjected. In a book written by Mr. T\^-ining, 
on Diseases oi the Spleen, as occmTing in hot climates, the author 
absented, that ■■ most patients labour under ditficult respiration, 
impaii-ed appetite, slow digestion, imperfect assimilation, despon- 
dency, inactivity, i^c. In the absence of active pyrexia, the urine 
is pale and often copious. In the latter stages, there is cedema of 
the feet, and sometimes of the face. In the majority of fatal cases, 
the patient dies of dysentery or ascites.'" ' I may mention that this 
author's experience leads him to oppose the use of mercury in 
diseases of the spleen. I here leave the subject of the spleen : 
ha%riiig said thus much, in order to excite your attention to the 
subject ; and, in the mean time, we must be satisfied, I apprehend, 
in looldng to the liver as connecting the spleen in the general class 
of sympathies. 



PANCREAS. 



We have little to say about the pancreas. Its fimction is im- 
portant, no doubt, since types of it are developed as early in the 
animal kingdom as those of any organ ; the stomach, perhaps, and 
liver excepted, it is rarely diseased. Mr. Abemethy mentions 
one case of it in a medicc:.! man, in whom the symptoms were indi- 
cative of svmipathy will. :_e -romach ; vomiting being very frequent 
after taking food, when also the pain was most acute ; the latter 
being probably o^ing to pressure from the distended stomach. 



* There is a case of hemeralopia, mentioned in the Transactions of the College 
of Physicians (by Dr. Heberden, I think), as succeeding to intermittent fever. 



The greatest relief from suffering was obtained by bending tlie 
body forwards on tlie knees, w^liicli might be supposed to relieve 
the pancreas from pressure. 

THE HEART PRIMARILY CONSIDERED. 

The sympathy of the heart with all parts of the body is very 
marked, and, in many respects, well known ; and, indeed, when we 
consider that it is the prime and principal mover in the distribution 
of the blood, we can hardly imagine that it could be otherwise. 
Thus we find that all affections of the heart are attended, in differ- 
ent cases, by disturbance and ii'regularity of different organs ; such 
as pain and confusion in the head ; apoplexy, noise in the ears, 
flashes or pulsations in the eyes, general nervousness, and increased 
sensibihty ; oppression and dyspnoea, as regards the lungs ; and 
sighing and yawning, as if the diaphragm sympathized ; irregu- 
larity of the bilious secretion and costiveness, purging, or piles ; 
disturbances of the urinary function ; dry, harsh skin, with occa- 
sional sudden and profase perspirations. 

That excessive action of the heart, which we call palpitation, 
is also an occasional attendant on disorders of various other 
organs ; as indigestion, congestion of the liver, and torpid bowels. 
Disorders of the urinary organs occasionally produce very dis- 
turbed conditions of the heart. One of the most remarkable 
intermittent pulses I ever felt, apart from organic disease, appeared 
to arise from an affection of the urethra. Pale, copious urine, and 
otherwise disordered states of that secretion, frequently accompany 
both frmctional and organic disease of the heart. The heart, too, 
seems to form a hnk in the chain of phenomena when fear pro- 
duces so great and so sudden a flow of pale urine. Hysteric affec- 
tions, in which the same thing occurs so commonly, are also 
attended by a very irregular condition of the heart's action. In 
many cases, however, this phenomenon is very complex ; and, 
although the heart is evidently a link in the chain, it is not often 
easy to make out its exact relation, since sometimes it, sometimes 
the kidney, sometimes the skin or uterus, may be primarily 
affected. 

The heart and arteries may be considered as parts of the same 
organ ; since I suppose the idea that the arteries are mere passive 
tubes, or at least acting only by an elastic property, is now well 



168 



nigh abandoned. The sympathies between the different parts of 
this general apparatus for the distribution of the blood are highly 
interesting ; and are nearly, if not entirely, the causes of the phe- 
nomena of the pulse ; the observation of which, you know, is often 
of so much consequence. Mr. Hunter has treated of this subject 
with his usual acumen. Now, the various kinds of pulses are ex- - 
tremely difficult to convey by description ; but a general view of 
them to help you to farther observation may be useful. In the 
first place, we may state, that pulses differ in power ; secondly, in 
their manner of evincing it ; and lastly, they have certain pecu- 
liarities which may exist in all degrees of power; and therefore, 
for the purpose of our present consideration, may be regarded as 
independent of it. 

In the first place, the power, as absolutely strong or weak, is the 
direct indication of the force of the heart's action; secondly, the 
manner as regards slowness or frequency ; thirdly, the quickness 
of the beats, as distinguishable from the interval between them ; so 
that a pulse may be frequent, that is, may beat 100 in a minute; 
and yet may not be, in the sense in which I have used the word, 
quick ; or it may beat 70 in a minute, and be quick. The quick, 
sharp, kicking pulse, seems referrable to the heart ; and all these 
states may be independent of any particular condition of the ar- 
tery : but when we consider hard, soft, full, or small wiry, and some 
other varieties of pulse, we arrive at characters which evidently 
depend on the condition of the artery, and which appear to be sym- 
pathetically induced, sometimes by the condition of the heart, 
sometimes by that of the system ; most commonly, no doubt, by 
both in conjunction. When the heart is oppressed, it would seem 
that the artery sympathizes w^ith it, and this in states very oppo- 
site from each other. 

There is a full, plethoric state of system, in which the heart 
appears, in its diastole or relaxed condition, to receive a large 
quantity of blood, and to expel it by a somewhat sluggish, yet 
effectual effort. In this state the pulse seems to expand easily, to 
help, so far as it can, the power of the heart, by giving the blood 
free ingress into the vessel. If any cause disturb this condition of 
the circulation, the heart, becoming more irritable, acts more fre- 
quently ; and there oc(mrs a different state of artery. There is 
still a large vessel, but it is not soft ; there would seem to be a 
disposition to resistance to the circulation in the artery ; and the 
pulse, though still full, is hard, and not unfrequently pulsates with 



169 



a sort of bound or kick Perhaps no state is more indicative of 
simple plethora than the one in question. 

If the heart be oppressed in another way, it would seem that 
it does not largely relax ; or it does not contract, so as completely 
to empty itself ; and that, in either case, a less quantity of blood 
flows into the arteries, which accordingly diminish their calibre by 
contraction ; and the pulse becomes small, and usually hard and 
wiry. Tf this state occur from debility merely, the same want of 
power felt by the heart seems to affect the contractile force of the 
artery ; and the pulse, though small, may be soft, even so as to 
suggest an unnatural degree of this property. The first case is 
seen in inflammatory affections, attended with depression of vital 
power, as in some cases of peritonitis, and inflammation of the 
bowels ; the latter, in cases where large quantities of blood have 
been lost, and also when the system is under any depressing in- 
fluence, as sicki^^ss of stomach ; and I think I have seen it from 
the influence of tobacco. 

If the pulse be quick, in the sense in which I have used the 
term, it will be owing to the heart ; but characters may be com- 
bined with the sharpness of beat which involve other considera- 
tions. Cseteris paribus, quickness is never a test of power; on the 
contrary, it may be always, with a careful adjustment of that con- 
sideration, be regarded as partaking either of debility, or of a state 
that leads to it. It is an evidence of excitement, as contradistin- 
guished from power ; but as strong parts may be excited, it is not 
always so sure a test of weakness, as of a tendency to that condi- 
tion, from the effects of excitement, which has always a tendency to 
exhaust power. It is also true, that it is sometimes a direct evi- 
dence of weakness, as debility is very excitable ; and thus, some- 
times a pulse of a very weak system will really simulate strength, 
so as to make this, in some mixed cases, one of the most difficult 
distinctions in practice. 

Now, here the sympathy of the arteries with the heart seems 
to me to afford much information, though I do not say that it will 
be an unerring guide ; but whenever a pulse imder excitement 
simulates strength, it is seldom hard ; it has usually a softness not 
in keeping with the other phenomena which are observable. I 
have seen this state of pulse in erysipelas, and I suspect that, it 
has often led to a pernicious abstraction of blood, from the falla- 
cious character of strength which it exhibits. The truth is, pro- 
bably, that the heart is acting with great excitement, but with 



J70 

really little vital "^ow ex ; and tlie arteries yield to the impulse by 
a kind of consent of action — a sympathy accommodated to the 
actual, as distinguished from the apparent, strength of the pro- 
pelling organ. I think, therefore, in determining the question of 
bleeding, I should, cseteris paribus, be much influenced by the 
hardness or softness of a pulse, concerning which it was desirable 
to determine the question of power, as suggested by any combina- 
tion of strength and quickness of beat. 

Suppose, for example, we had a case of idiopathic erysipelas, 
in which the progress of the disease, and the general condition of 
the patient, put the question of bleeding otherwise on a par. If 
the pulse were strong, quick, and soft, I should say try other me- 
thods of lowering the vascular action : if it were hard, or even firm, 
I wonld say bleed, — that is, as I would bleed in erysipelas, — of 
which I shall speak hereafter. Notliing, I conceive, can be deter- 
mined with regard to the question of how much, in this state of 
pulse may be attributable to power, and how much to excitement, 
by a pulse glass, or any other mode of ascertaining the actual force 
of the heart at the time ; because excitement will produce as great 
momentum at the time, and often more, than we witness in actual 
strength; just as voluntary muscles will, under certain states of 
excitement, evince a power of which, under ordinary circum- 
stances, they would be incapable ; so that we must not assume that 
mechanical force is a just indication of vital power. Impressions 
on the skin exemplify the ready sympathy between the arteries and 
heart, whether direct or intermediate. 

Thus the reaction after cold, and the experiment with which I 
set out — that of placing the finger in hot water — proves the rapid 
consent of action between these parts. Blisters on the skin often 
produce effects, exempKfying, in a more or less striking degree, the 
ready influence exercised on the heart by impressions on the capil- 
lary circulation. You will find, in Dr. Whytt's works, a series of 
cases, which he records to shew the effects of blisters in loivering 
the pulse. 

However, we must not refine too much in illustrating this sym- 
pathy. It is sufficient to shew that there is, for the most part, a 
very discernible sympathy between the heart and arteries, and that 
a careful consideration of either will generally assist in appre- 
ciating the real condition of the other. The sympathies of ar- 
teries, however, are exceedingly interesting with reference to their 
minute and ultimate divisions, those vessels in fact, which, as Mr. 



171 



Himter sajs, are tlie modellers of the body, and on whose consent 
of action with the absorbents the form and bulk of parts essen- 
tially depends. Their sympathy with various states of the system, 
and with the arterial system in particular, are of great importance, 
as leading us to sound views, if they do not explain the deposition 
of tumors and other diseased depositions. 

I shall therefore mention a few instances in which the heart and 
arteries are sympathetically affected ; since, in any subsequent en- 
deavour to explain why the minute arteries act in this or that 
manner, it will be a very necessary element in the enquiry, to 
ascertain any cause which can make them act in any way, so as 
to evince a demonstrable connection with any organ or organs. 
Now the phenomena already mentioned, in connection with the 
sympathies of the skin, shew that affections of the digestive organs 
produce unusual activity in the capillary circulation ; because red- 
ness cannot take place without it. Redness is not essential to 
activity of the capillary circulation ; but activity of the capillaries 
is essential to redness. I mention this, because hereafter you will 
find it an important distinction. 

Affections of the heart, especially through the mind, produce 
certain phenomena in the minute vessels, of which blushing is an 
instance : and therefore anything which affects the heart, may affect 
the capillaries also. This brings us again to the sympathies of the 
heart itself, which we see exemplified in almost every disease of 
every organ ; but as this has been pretty fully considered in dif- 
ferent parts of the foregoing observations, and will be again men- 
tioned with the subject of joints, I need not repeat them here, nor 
anticipate the application of the several phenomena. The sym- 
pathy of the heart with the mind will, however, be somewhat more 
fully considered when the mind is the subject of discussion. 

UTERUS, PRIMARILY CONSIDERED. 

No organ more strongly demonstrates the recognition which 
takes place between all parts of the body than the uterus ; since 
there is no one part of the body with which it does not sympathize. 

The innumerable forms of hysteria wliich, in different persons, 
simulate almost every complaint with which we are acquainted, 
substantiate this position. You must not conclude, however, that 
all cases of hysteria originate in the womb. I am well convinced 



172 



the fact is far otherwise, and that the womb, in a great many of 
them, is secondarily affected ; the primary disorder being in the 
stomach, liver, or bowels, or in all these parts, to affections of 
which, the habits of women render them so obnoxious. The 
womb, nevertheless, is very commonly deranged in its functions, 
and, as it is subject to disordering influences, in many cases is, no - 
doubt, primarily affected. We find that disorder of the womb will 
produce sickness ; loss of appetite, or a voracious or fitful desire 
for food ; purged or costive bowels ; great flatulency ; torpid state 
of the liver ; disturbed condition of the kidney, sometimes evinced 
by scanty and thick, but more generally by copious and pale, 
urine ; disturbance of the mind, melancholy and foreboding, or 
high spirits without sufficient cause, torpor, or even fainting. Pal- 
pitation of the heart, oppression about the chest, and sighing, are 
frequent concomitants of hysteria. I have seen a woman with 
symptoms exactly resembling those of stricture of the rectum, 
and then those of stone in the bladder, which were dependent 
on the condition of the uterus. 

Cramps of muscles, pains in the joints and limbs, are also not 
unfrequent in affections of that organ. Sydenham, alluding to the 
general symptoms of hysteria, says, that Proteus had not more 
shapes, nor the camelion so many colours. Constant cough ; 
pain like a stone passing the ureter; acid and gaseous eructa- 
tions ; vomitings of green bile ; " Anger, jealousies, suspicions, 
and other passions ; a wavering and unsettled state of mind ; 
constant to nothing but inconstancy ; salivation ; night sweats ; 
may be enumerated, amongst a variety of others, as symptoms of 
hysteria," 

As the symptoms mentioned shew, in reference to the respec- 
tive parts, the universal sympathy of the uterus, I need not in- 
crease the catalogue. I would, however, observe, that the fact of 
the uterine affection not being primary, in many cases, and not ex- 
isting in a distinguishable manner in others, is a very important 
circumstance, as helping us to the explanation of hysteria ; and if, 
with this, you recollect that hypochondriasis in men, which is often 
connected with deranged liver or stomach, often presents many of 
the same symptoms that hysteria does in women, you will have all 
the elements necessary for the consideration and adjustment of the 
real influence of the uterus in the phenomena of hysteria; and 
which I think you will find, for the most part, owing to primary 
conditions of disorder in some other parts of the system. In con- 



173 



nection with the sympathies of the uterus, it is very important to 
recollect, that many of those disorders which accompany preg- 
nancy do not exclusively belong to that condition. In short, I 
know of none of what may be called the symptoms of pregnancy, 
as regards other organs, which may not attend other conditions of 
the uterus ; and this suggests, what I think experience abundantly 
justifies, that many of the severer sympathetic disturbances which 
accompany utero-gestation, are, in fact, not so much to be referred 
to that state, per se, as to a disordered condition of the system ; 
which gives rise to sympathetic disturbances, often relievable, but 
generally left to take their chance, as it were, on the supposition 
that they arise from natural, and therefore uncontrollable, sym- 
pathies in the individual. 

I have known a lady suffer constant sickness in pregnancy, which, 
on a subsequent occasion, has been entirely removed by attention 
to derangement of organs on which the sympathetic disturbance 
was thus proved to depend. This, truly, is a subject falling more 
under the province of accoucheurs ; yet surgeons are occasionally 
consulted where there is any idea of organic affection, either of the 
uterus, mammoe, or rectum. Cases of this description have pre- 
sented to me some curious facts in relation to the sympathies of 
the uterus, as throwing some light on the preceding observations. I 
have mentioned a very remarkable case already, in speaking of the 
sympathies of the alimentary canal, simulative of pregnancy. But 
I could mention a variety of instances, shewing how disorders of 
the uterus have occurred, as sympathetic with other disorders of 
function ; and which satisfactorily explain, why measures directed 
to other organs frequently succeed in correcting deranged condi- 
tions of the uterus, in which steel, myrrh, aloes, and other reme- 
dies, supposed to have more direct effects on the uterus, have 
failed. In many cases, and I think in almost all of deficient ca- 
tamenia, the skin is more or less affected ; and applications to it, 
either by means of sudorifics, taken internally, or by warm baths, 
prove very successful emmenagogues. 

In some physiological essays, written by Dr. Stedman, some 
seventy years ago, there is one on menstruation ; in which the 
relations of the skin and uterus are dwelt on as observed by Sanc- 
torius. Dr. Friend, and others. Indeed, Dr. Friend proposed a 
theory of menstruation, which made it depend on a relation it was 
supposed to bear to the functions of the skin. I merely mention 
this circumstance to impress the feet of the consent of action ob- 



174 



serv^ed between these organs. I have, however, already sufficiently 
adverted to the sympathies of this organ ; and the multiplication of 
their illustrations here is unnecessary. The fact that I would 
impress now, and further I cannot conveniently enlarge, is, that 
most cases of disordered uterus depend on other parts having 
been primarily disordered; and that the correction of such dis- 
ordered functions, whether of the alimentary canal, liver, or other 
parts, renders many cases, otherwise wholly intractable, not only 
very curable, but also with the greatest facility. 

TENDON ; BONE ; AND STRUCTURE OF JOINTS GENERALLY. 

I have placed these together ; because all that is necessary to 
say withregard to any of them, applies more or less to them all. All 
parts whose functions seem to require what is called low organiza- 
tion, are chiefly characterized, either by the absence of red blood, 
or by the diminution of that sensibility whith which parts are or- 
dinarily endowed. Now Mr. Abernethy, and, I believe, Mr. Hunter 
also, observed that parts most disposed to suifer in general disor- 
ders of the animal ceconomy, were parts of least life and most 
susceptibility. The structures here considered fall under this de- 
scription ; and we certainly find that they are particularly prone to 
become disturbed by general indisposition. Common cold, gout, 
rheumatism, diseases of joints, scrophula*, are all so many fami- 
liar examples of this tendency ; whilst different cases shew the 
sympathy of the structures in question with various organs ; one 
with the stomach, another with the liver, a third with the skin, or 
with all these in conjunction, and so on. The most important 
thing, however, to remember, is, that that sympathy which is 
glaringly demonstrated in peculiar diseases, as gout, &c. is not less 
real in affections of joints usually considered to result from " com- 
mon inflammation," — that is the important fact to be impressed on 
you. 

Rheumatism sometimes presents us with a fearful illustration 
of the sympathy of the heart with these structures ; since a fatal 
transition of the diseased action of the heart is by no means a very 



* Mr. Hunter says, vol. i, p. 346 : — " A gentleman had an anchylosed knee 
and ankle-joint from scrofula ; and he was always deaf at the full of the moon, 
except in autumn, when his sores discharged plentifully." 



175 



infrequent occurrence. That of gout to the stomach is also well 
known. There is a very curious case related by Dr. Wilson of 
Kelso*, in which a man had gout in his foot, which gradually left 
part after part, until it reached his stomach; when a violent vo- 
miting of green matter was attended with immediate and complete 
relief The universal derangement of the digestive organs in affec- 
tions of bones, joints, &c. is so well known, that it need only be 
mentioned. In diseases of bone of a chronic kind, nothing like 
adequate attention has been paid to the mutual sympathy between 
this structure and the general system ; but the march of improve- 
ment has, I think, begun ; and we shall find that general measures 
are more regarded, and local less, even in diseases of bone. To 
shew the present state of science as regards this subject, I may 
mention a case. A woman had for a long time a violent pain in a 
particular spot in her tibia ; it was thought that matter had formed 
there, as such cases have been accompanied by such symptoms. 

So far, so good ; but the surgeons who saw her proposed to 
trephine the head of the tibia — -an operation of which, in one's 
own person, I suppose, we should like to be well convinced of the 
necessity. Now all tliis might have been necessary ; but now let 
us consider the remaining part of the case. The woman was ex- 
ceedingly out of health : she distinctly stated that her health had 
been impaired before the occurrence of the pain, which I myself 
made a point of communicating to one of the surgeons ; and, 
lastly, this was in a hospital. Now, I would ask, would it be pos- 
sible, bearing in mind the sympathy of bones, &c. with the general 
health, or even the general announcement of the principles of 
Hunter and Abemethy, — nay, would it be probable, that any men 
could, in such a case, and under such circumstances, entertain such 
a proposition ?t I know I was surprised and extremely vexed at 



* On Morbid Sympathies, &c. 

t Mr. Stanley gave, this year, some very good Lectures on Diseases of Bone, 
at the College of Surgeons ; but they might be regarded more as the natural his- 
tory of such diseases than as any attempt at investigation into the pathology of 
these diseases, strictly so termed. Mr. Stanley, I hope, will yet pursue this sub^ 
ject, by an enquiry into the various conditions of the system, by the action of which 
the various changes of structure are produced ; otherwise, the facts which he has 
collected, with an industry highly commendable, will scarcely repay his labour, as 
regards the light which they will throw on the treatment of disease. They are 
rather to be regarded as the natural history of diseases of bone than as elucida- 
tions of their pathology : but of the relations of morbid anatomy to pathology, I 
have already spoken ; see Discourse I, p. 9, et seq. 



170 



tlie time ; but not a little rejoiced to find that no persuasion could 
induce the woman to submit to the operation. The rest of the case 
may be related in a few words ; namely, that she recovered with- 
out any operation at all. In short, every thing I see around me 
convinces me that there is no sustained effort to unravel the laws 
of the connection of all parts of the body with each other ; and- 
this impels me to insist, so far as an humble individual can, on its 
study — not only as necessary to the progress of medical science, 
but as a duty to those who profess it. 

Affections of bones, joints, &c. as connected with the urinary 
organs, are well known ; and the gonorrhoeal rheumatism is a glar- 
ing example of this sympathy. A very important sympathy is 
here also unfolded, namely, that of fibrous stractures ; as tendon, 
ligament, &c. with mucous membranes. Any affection of the 
membranes lining any of the canals of the body, is competent to 
affect the joints, tendons, fibrous membranes, fascise, &c. ; and the 
sympathy is reciprocal : but disturbances of the mucous surfaces 
of the alimentary canal, or the urinary organs, more frequently 
affect the fibrous structures, — as of the head (dura mater), and of 
the heart (pericardium), besides ligaments, fasciae, and the struc- 
ture of joints, — than the fibrous structures affect the mucous. So 
much, however, must necessarily be said in a subsequent volume, 
in connection with these important parts, that I need not enlarge 
further on their sympathies. 

MUSCLES. 

I have already mentioned some sympathetic phenomena of the 
muscular system, in speaking of cramps, convulsions, St. Vitus's 
dance, and tetanus. In rheumatism, a disease which exemplifies 
sympathy with different organs in different cases, it is well known 
that the muscles are very generally affected ; sometimes by a loss 
of power, and by a refusal to contract ; at other times, contracting 
involuntarily \vith gTeat pain. I need not enlarge on these sub- 
jects in this place ; but shall mention one or two familiar occur- 
rences, shewing the sympathies of these parts in a somewhat 
different manner, in certain conditions of the system. The most 
simple primary affection of the voluntary muscles, and it is of them 
that I now speak, is fatigue ; and, of this condition, we find most 
other parts of the system affording recognition. The heart beats 
less powerfully ; the diaphragm acts more slowly ; and, as it were 



from necessity arising ont of those resnlts, the lungs also. A veiy 
interesting and important condition of the muscular system, as 
helping us to discover what we have often great dif&cnlty in de- 
tecting, is an apparently sound state of health, as distinguished 
from real vigour — a discrimination which we cannot make, either 
by the feehngs of the patient, or by observation of the functions of 
any other organs ; but which is, nevertheless, often shewn by the 
muscular system, in a very ob™us manner, both in its nature and 
(in a case of accident or disease) its consequences. This state is 
well known in animals ; and to many in regard to man ; and is 
what is usually termed condition. If the body be in a high, real 
health, and all its functions proceeding with vigour, the muscles are 
very firm ; and, when they act, become extremely hard and un- 
jdelding : we find, too, that they act with a vigour much more 
sustained, as well as increased ; and that, in this state, they are 
very good general indications of the state of the vital powers. 
Diseases seldom occur under these circumstances ; but accidents 
very often : and, notwithstanding that they frequently involve in- 
juries of a very extensive nature, we seldom find any other mea- 
sures necessary than tranquillity ; and, perhaps, some diminution of 
the circulating fluid. 

Many circumstances prove the connection of this condition of 
muscles with vigorous health. In pugilistic contests, we have often 
seen the very severe injuries which the body sustains in various 
parts : a man has stood up for more than an horn', with very short 
intermissions, perhaps of one minute, seldom exceeding a minute 
and a half; and, after receiving a vast number of severe blows, 
and having been carried off with his powers quite exhausted, and 
sometimes senseless, he will often appear again, in a few days, 
having, to all appearance, very little the matter. The contrary 
sometimes happens ; and a pugilistic contest proves fatal to one of 
the combatants : but this is equally instructive ; for, besides that 
such an event is extremely rare, it almost always happens that it 
is in what used to be called a " turn-up fight," that is, a fight got 
up on the spot ; or else in cases where the sufferer was of careless 
habits, or had not undergone the requisite framing . The trainers 
of race-horses, also, know very well the effect of the general health 
on the muscular system, and the sustained vigour which it gives 
to the wind and speed of the animal. The muscles of all wild 
animals which are almost always in condition, and which are sub- 
ject to scarcely any disease but old age, are remarkably distin- 

N 



178 



guished from those of tlie same species in domestication. Tliej 
are always firmer, and redder ; and require, as we know, much 
longer keeping after death to render them tender. In many cases, 
if you feel the muscles of a man who has some indication of ill 
health, of which his feehngs do not apprize him, you will almost 
alw^ays find them soft and flabby, and that he is easily fatigued. 

I have often been surprised to see, in convalescent states, how 
very soon this condition of muscle alters under the usual treat- 
ment ; such as air, exercise, and more nutritious food. A week 
will often make a difference, which it is impossible to conceive can 
result from organic differences in the muscles, but which must be 
referred to an increased vitality given them through the nervous 
system. We have a proof of this in cases where muscles are re- 
newed in their vigour by a single meal, which shews the ready 
sympathy they manifest with the condition of the nervous system. 

The diaphragm is an example of extensive spmpathy in a sin- 
gle muscle. Its ordinary alternate action, with the abdominal 
muscles, is a beautiful example of consent of action in the per- 
formance of respiration. Its participation with the heart and mind 
in sighing, sobbing, &c. is well known. This muscle, one of the 
most interesting structures of the body, presents, indeed, a vast 
number of facts for useful reflection ; but, as I am not teaching 
physiology generally, it would carry me away from mj' subject to 
enter into them. 

The sympathy of muscles with the parts with which they are 
connected is highly interesting. How wonderful that the laws of 
volition should be constantly modified for the safety of the indi- 
vidual. If a part be broken, bone or tendon, that Will, which 
held the muscles in subjection to its mandates, and w^hich acted on 
them with a celerity to which we know nothing analogous but 
electricity, is no longer capable of exerting its power. The will, 
indeed, may act, but not so the muscle : and in other cases we ob- 
serve the converse of this ; the muscle will act, though it be ordered 
by the will not to do so. This w^e see in dislocations. Nothing 
prevents the bone being replaced but the muscles : the patient tries 
with all his power to relax them ; but they hold the dislocated bone 
with ungovernable pertinacity. Here is sympathy, indeed ; the 
muscle seeming to sympathize with injured parts, and to exert a 
specific influence independent of that power to which it is usually 
subservient. Now all this I would have you think on at leisure by 
and by. Mr. Hunter observes also that muscles shrink in the 



179 



neighbourhood of a diseased joint, and we say that it is because 
they are not used. This may be, in part, the right explanation ; 
but, as Mr. Hunter observes with his usual acumen, if this were 
the case, we should have the muscles of the opposite limb, when 
the patient is at rest, shrink in the same manner ; which we do not 
find to be the case. 



CELLULAR TISSUE. 

The connecting medium betw^een all parts of the body, by 
means of that elastic form of animal matter which we find between 
the skin and muscles, and between different muscles, and which we 
call cellular tissue, has peculiar properties, many of which range 
themselves most conveniently in the catalogue of sympathies. The 
cellular tissue, like many elastic substances in animals, is not very 
sensitive: it has no functions under ordinary circumstances but 
those of connecting all parts with each other ; and, although vari- 
ous circumstances shew how- speedily it sympathizes with other 
parts, yet, so long as the effects are strictly confined to it, other 
parts do not shew much disposition to sympathize with it. Thus, 
various tumours grow in the cellular tissue without producing dis- 
turbance ; even cancer may be there for an indefinite period, and 
yet uot produce reaction. 

The phenomena of dropsy shew the readiness with which the 
vessels of the cellular tissue sympathize with other parts : yet how 
little reaction a very great disturbance of this tissue produces. 
This is partly, perhaps, from its elasticity, and partly from its not 
being a very sensitive structure. Nevertheless, we cannot say 
that cellular tissue is not highly organized ; for, in truth, it shews 
plenty of evidence of abundant vascularity. Now the foregoing 
remarks are made chiefly in reference to the functions of the cel- 
lular tissue as a connecting medium — a function, the integrity of 
which is highly important to the ease and comfort of the various 
fiinctions of the parts which it connects — but still it is a part whose 
functions can be interfered with, with greater impunity than those 
of any other structure in the body. 

In this respect, cellular tissue presents a situation where the 
various products of diseased action may be deposited with less in- 
jury to the animal than any other ; and accordingly we find that it 
is by far the most common situation for such depositions. Now 



180 



this consent of action in the vessels of the cellular tissue, we have 
great difficulty in explaining in any other way than by referring it 
to the sympathy which it possesses with all parts and with the 
whole system. When we consider the different forms of inflam- 
mation, we shall find that a great variety of them have their prin- 
cipal seat in the cellular tissue ; and that, in many of them, the 
cellular tissue not only allows a convenient situation for the dis- 
eased action, but, by a process of tliickening, prevents the inflam- 
mation from becoming diffused, as it would do were such thickening 
not to take place. We see this in common phlegmonous abscesses, 
in boil, and less frequently in carbuncle. The effect of this ab- 
sence of thickening, or at least an accompanying circumstance, is 
seen in the diffused extension of erysipelas. 

If we examine into a very difficult part of surgery, namely, the 
origin, growth, and nature of tumours, of which the variety in 
form, character, and progress, is almost endless, we shall find that 
they generally commence in the cellular tissue ; and, although 
we cannot say that this is a law, until we explain the ex- 
ceptions to it which we observe, yet these exceptions may, as far 
as regards the ordinary observation of diseased depositions, be 
truly regarded as variations from a general rule. Fatty, fibrous, 
encysted, and a great variety of other tumours, evidently commence 
in the cellular tissue ; and many of them, though they arrive at a 
great bulk, are seldom seen to affect any other structure. Even 
malignant tumours, if examined at their commencement, are almost 
invariably seen to commence in this structure ; and, in thickening 
of canals, the same circumstance is generally sufficiently ob- 
servable. 

It is not very often that we have an opportunity of observing 
this ; but I am certain that I have seen thickening of the intestines, 
in which neither the muscular nor membraneous structures seemed 
to have as yet participated. Neither are we necessarily to infer, 
because we see a glandular structure changed, that the disease may 
not have commenced in its cellular tissue ; since there is no part 
without this connecting medium, and since the disposition to dis- 
eased deposition in it seems so common and so universal. Now 
all this is, in a pathological point of view, extremely important ; 
because, — if we see that there is a law, or if we see that there is 
a disposition for diseased actions of the system to deposit various 
kinds of matter in different parts of the body, and if we observe 
that this usually commences in the cellular tissue, or, in other 



181 



words, tliat there is a certain consent of action in the vessels of 
cellular tissue to take on the business of such diseased depositions, 
— we shall arrive, not only at a more enlarged view and scientific 
treatment of tumours, but we shall readilj understand how it is 
that certain improved conditions of general health are accompanied 
by the removal of such tumours. 

Of such occurrences, many examples have occurred under my 
own observation ; and what has tended to impress the fact more 
strongly on my mind, is, that many of these tumours have been of 
a nature, I will not say cancerous, because I had not the oppor- 
tunity of examining them by dissection ; but this I will say, that 
several of them were such as I believe no one would have hesitated 
in pronouncing to be true scirrhus, so far as the most careful and 
accurate examination of the cases could enable any one to deter- 
mine. Of these I have met, in the course of sixteen years, with 
about six or seven cases. I have not, unfortimately, kept notes of 
them ; but they have all been, more or less, similar in their his- 
tory. They have occurred in the breasts of women who have 
been about the age when the catamenia cease ; they have been ex- 
tremely hard, have existed for a considerable time, and have begun 
to be painful. Operations have been proposed and assented to ; 
when, on preparing the patients by puttiug them in- good health, 
the tumours have undergone some change which has postponed the 
operation ; and, in the end, the tumour has gone away. In the two 
last cases which I saw, I so far predicted the result as to say, that, 
notwithstanding I had proposed the removal of the tumour, yet 
I had seen apparently as genuine a case of scirrhus as those 
under treatment, go away on the correction of the general health. 
There was a woman, last year, in the Dispensary, whose case I 
have lost sight of, in whom there was a tucking-in of the nipple, 
and every other symptom of carcinoma ; but she appeared to have 
some affection of the heart. This put the operation out of the 
question. During her treatment, which was chiefly directed to 
tranquillizing her circulation, the tumour became loose and smaller, 
and the nipple began to assume its ordinary appearance ; but I 
have, for the present, lost sight of the case. On this point, how- 
ever, you will hear more to the purpose, when tumours are the 
subject of a more practical discussion. I here only say as much 
as is sufficient to impress the fact, that, in certain disorders of the 
system in which tumours are deposited, the cellular tissue is the 
nidus in which such depositions usually take place ; and we cannot 



182 



understand why this should be the case*, further than by consider- 
ing that there is a general consent between the vessels of cellular 
tissue and the state of the system generally. This seems, in the 
absence of a better place, to range itself naturally under that corres- 
pondence between all parts to which we refer the phenomena of sym- 
pathy. The sympathetic phenomena, referring to the absorbent 
vessels, present us with much useful matter, in connection with 
some of the foregoing observations ; but, were I to enter into that 
now, I could scarcely help a repetition hereafter, which I am 
anxious to avoid. The phenomena of sympathy can never be 
fully treated, unless in a work expressly devoted to it ; except they 
be interwoven with the discussion of the history, treatment, &c. of 
different diseases. This I shall endeavour to accomplish so far as 
is practicable : in the mean time, those mentioned may be sufficient. 



BRAIN. 

As the brain and the nerves (the whole of which are connected 
with it) are the sources of all our sensations ; and as the former, 
by means of the nerves, holds communication with every part, of 
course its sympathies are well marked, and universal. The sym- 
pathy of the brain would alone require a very considerable space 
for its full discussion ; but what is necessary to an elementary 
view of the subject, may perhaps be comprised in a few pages. 
The brain may be said to manifest two kinds of sympathy, very 
different in kind ; the one common to all parts of the body, and 
therefore what may be called its physical or corporeal sympathy ; 
as exemplified in various kinds of pain, increased determination of 
blood, bursting of its vessels, inflammation, and so on. The other, 
that kind of sympathy which consists in the derangement of its 
functions, as the organ of the mind ; and which may, in contradis- 
tinction, be termed its moral or psychological sympathy. Now, as 
regards the former, the fact of the head becoming variously dis- 
turbed by different disorders of other parts, is so familiar that it is 
not necessary to say much on that point. The physical sympa- 
thies of the brain are demonstrated like those qf other organs ; 
that is, by pain, or some other alteration in its sensitive functions. 



* This subject will be renewed in connection with the consideration of the law 
of inflammation. 



183 



In this class I would iucliide pain, giddiness, throbbing, noise in 
the ears, illusory vision, and so on. Now enough has been said on 
this kind of sympathy in connexion with other organs ; and I 
M^ould here only connect with it one important fact, — namely, that 
disorder of the brain, thus arising sympathetically from affections 
of other parts, but more especially from the digestive organs, and 
which was originally unattended by any organic change, will, in 
many cases, if the disturbing influences be continued, ultimately 
end in alteration of structures. Now this is a very important fact to 
be remembered ; and although there can be no doubt, that, in cases 
where the brain is diseased, and the chylopoietic functions are found 
much disturbed, the brain may sometimes be primarily affected ; 
yet it is at least equally certain, that in many cases the cerebral 
affection is secondary. This, however, is a point wliich does not 
admit of philosophical demonstration by the mere narration of 
cases; although the observation of them, to my mind, affords 
nothing less to the individual in whose experience they occur. 
For where we observe repeated recurrence of disorder of the 
chylopoietic viscera constantly relieved by the most simple atten- 
tion to their functions ; where the disorder only recurs on the 
recurrence of the causes which produced it ; where at length ce- 
rebral disturbance becomes superadded on the later attacks ; and 
where the disturbance, beginning in common headache, then affects 
the external senses, and subsequently terminates in paralysis and 
structural disease ; — I know not how we can resist the conviction 
which such a series of phenomena forces on us. I have already 
mentioned a very striking case of this kind in illustration, in con- 
nection with the liver. 

Every one knows that disorders of the various viscera affect 
the head in the modes already alluded to ; and that a plethoric 
condition of the system, generally, or of any particular viscus, is 
especially apt to occasion cerebral disturbance. It is equally true, 
though perhaps not quite so trite, that an opposite condition of the 
system will, in many instances, produce very similar disturbances 
in the head. Thus, too copious an abstraction of blood, either by 
art or accident, is very commonly attended by throbbing and other 
derangement of the cerebral circulation. In tardy convalescence, 
and also in the early period of convalescences, which are satisfac- 
torily progressive, we frequently have evidence of the same dis- 
turbance. I had a very interesting case of this kind in a gentleman, 
who had been confined to bed about three weeks, in consequence of 



184 



a disorder connected with his urinary organs, occurring at a time 
when he was out of condition. On his recovery from that dis- 
order, he was troubled by symptoms wliich, under other circum- 
stances, would have been as alarmingly as they were closely 
simulative of imperfect amaurosis. I told him that, in my opinion, 
there was no reason for alarm, and that he would find, that as he - 
regained his strength, wliich he would, now that he returned to 
exercise, better diet, &c. his amaurotic symptoms would subside ; 
but that perhaps it would be satisfactory to see if a different view 
could be taken, and that, therefore, it might be more satisfactory 
to have a consultation. In this consultation, although the general 
correctness of the view which I had taken of the case was admit- 
ted, yet there was, on the part of the gentleman with whom the 
consultation took place, a disposition to attribute something to a 
slightly vascular condition of the membrane lining the eyelid ; and 
a wash and some other local application recommended. As I 
could not participate, in any way, in this view of the matter, the 
patient declined doing anything of this kind : and the result of the 
case proved the correctness of the opinion which I had entertained ; 
for, as his strength improved, the amaurotic symptoms retired, as 
had been predicted. 

As the exemplifications of this sympathy will so frequently 
present themselves, and as they are already so well, perhaps even 
popularly, known, I will say no more of them here, but proceed to 
consider the sympathies of the brain as the organ of the mind, — 
the sympathy, in fact, of mind and body. 

This is a very important subject, and one which has been by 
no means cultivated as it ought to have been, but which promises 
practical results of the highest interest. For that the mind gene - 
rally sympathizes with the body, no one will deny ; and the two 
following propositions appear scarcely less demonstrable. First, 
that any function of the mind may sympathize with any part of 
the body ; and, secondly, that, notwithstanding this, certain parts 
of the mind exhibit a preference, at it were, in their sympathies 
with different parts of the body, and this reciprocally. 

This is exactly what happens between organs generally ; and I 
am desirous of impressing the fact, for reasons which will appear 
as we proceed. For example, then, suppose we take any two bo- 
dily organs ; say the uterus and kidney. There is no part of the 
body which may not sympathize with either ; but they each affect 
some parts much more frequently than others. Thus, the uterus 



185 



affects the stomach imich more frequently, perhaps, than any other 
organ ; and the same may be said of the kidney : although there 
is no organ which may not occasionally be affected by both of 
these viscera. So with the mind*. Disease of any organ may 
disturb the mind ; and, for aught we know to the contrary, in any 
way ; and again, disorder of the mind will disturb any organ : in 
one, the liver ; in another, the stomach ; in a third, the bowels ; and 
so on. But, notwithstanding this, it is very evident that the mind 
disturbs some organs much more frequently than others. Of this, 
the heart may be cited as tlie most familiar example. Then, when 
disturbance appears to occur primarily in bodily organs, it affects 
the mind in different degrees. Derangement of the biliary appa- 
ratus affects the mind with much greater certainty than derange- 
ment of any other organ. I speak this considerately, and not 
without due attention to the powerful sympathies of the stomach 
and uterus more especially. The hypochondriasis and melancho- 
lia of the ancients point very decidedly to this connection, and 
daily observation furnishes hundreds of additional examples of its 
its truth. The next proposition I w^ish you to consider, is this : 
If the mind has reciprocal sympathies with all parts, and yet ex- 
hibits different degrees of excitability with reference to, or in con- 
nection with, particular organs, why may not different parts or 
faculties of the mind exhibit different preferences in their sym- 
pathies with different parts of the body ? If this be so, it is clear 
that we have hitherto limited our attentions on this subject to a 
-very coarse generalization. Now, analogy directly favours this 
view of the mental sympathies, because it is unquestionably de- 
monstrable in respect to corporeal organs. 

Let us enquire whether we have any facts bearing out or justi- 
fying such conclusion. 

Now the heart is affected by the mind, doubtless ; but is it not 
most remarkably (w^e will not say frequently, because that may or 



Mr. Hunter observes, — " Strong affections of the mind will produce involuntary 
motions, even of those parts commonly at the command of the v^^ill." He also 
observes, " I suspect that particular parts may sympathize more readily with the 
mind than others." p. 329. And again he observes, at p. 359, " Indeed, there 
is not a natural action, whether voluntary or involuntary, that may not be in- 
tluencedby a peculiar state of the mind at the time ; and eyexy particular mode 
of the mind has some parts that are more readily influenced by it than others." 
Palmer's edition, vol. i. 



186 



may not be in point) affected by the passions, as love, joy, anger 
grief, and so on ? Will any man say that the heart is equally, or 
as demonstrably, disturbed by the intellectual functions ? But nei- 
ther the absolute influence of the passions on the heart, nor tlieir 
relative power, as compared with the intellectual functions, will be 
doubted. It remains, however, to be observed, that the passions 
themselves have something in common, and something peculiar. 
We assert that different passions disturb the heart in different 
modes, notwithstanding that we may be unable to describe these 
modes in detail, because we evidently perceive that they are not 
the same. It is one thing to see that things are not identical, and 
another to convey in what their differences consist. Nothing, for 
example, can be more different than the effect produced on the 
heart by fear and anger. Anger increases the action and power of 
the heart; fear depresses both. Phenomena, the same in kind, but 
differing in degree, are also produced by joy and grief. Joy tends 
to raise the heart's action ; grief to depress it. 

Now we are too much accustomed to think of all these passions 
as the act of one organ, comprising the whole under the general 
term of mind. This is all very well, if we recollect that this word 
mind refers to an assemblage of functions, which, whatever may be 
the depth of our ignorance, we at least perceive to be very different 
from each other. No greater difference is conceivable than that 
between joy and melancholy, hope and anger, despair and bene- 
volence. Hearing is not more different from seeing, nor smelling 
from tasting, than the different functions and feelings are from each 
other ; and, as the mind is thus made up of a set of functions, dif- 
ferent in their nature, or, at all events, extremely different in their 
operations, it seems not only reasonable, but in fact probable, that 
their sympathies will at least present the ordinary varieties in their 
operation. Now, if we commence with a grand division, as it were, 
of the mind, first into those functions which we call the passions, 
then into that assemblage of faculties denominated reason, we begin 
at once to obtain a glimpse, as it were, of different manifestations 
of mental sympathy. The passions are common to animals ; the 
rational faculty is peculiar to Man. 

Love, joy, grief, &c. are common to both : comparison, reflec- 
tion, judgment, the special attribute of Man. Now it will be 
found, on examination, that the sympathies of those propensities 
common to both are most remarkable in respect to organs with 
which both are also endowed in common ; for, although the pas- 



187 



sions do, at different times, most certainly disturb every organ in 
the body, yet it is equally clear that they disturb some organs more 
than others ; and, on examination, it will be found, I think, that 
they disturb those organs most frequently in which we can discover 
no difference between Man and animals ; such as the heart, lungs, 
liver, kidney, and perhaps spleen. 

The physiological characters of these organs are the same in 
in both cases ; but, when we consider the alimentary canal, we 
find very interesting differences. They have, it is true, several 
things in common. Their relation to the body is, in a word, the 
same in both ; their correspondence with the mind presents, as it 
appears to me, some interesting peculiarities. The alimentary ca- 
nal in brutes seems chiefly allied with their passions. In Man, 
this is also, to a certain extent, equally true ; but it is also, in a 
very especial manner, connected with his rational faculties*. Con- 
formably with this view, we find that the animal propensities in Man 
sympathize most readily with his mere animal organs, and that his 
reason sympathizes most markedly with his digestive functions. 
Now it would be only in conformity with this view, if we were to 
find that particular passions affected particular organs more com- 
monly than others ; and, for my part, I think that it is so. Anger 
certainly most readily affects the heart, perhaps also violent grief; 
sorrow (by which I mean grief, moderate but sustained), the liver ; 
fear, the kidney ; and so onf. 

Now this investigation is very difficult; but I wish you to 
consider it as part of a more analytical examination of these mat- 
ters, with a hope of getting useful practical results. If we 
proceed to the observation of the mental faculties, we perceive, I 
think, similar sympathetic connections between them to those which 
we observe between other parts ; that is, that the reasoning powers 
and the passions sympathize generally, but that there are consider- 
able differences in the readiness or in the manner of their manifes- 



* See Remarks on the Unity of the Body, art. Brain, where this point is more 
fully considered. 

t " Fear often brings on a flow of pale urine." — Whytt, page 134. So 
Hunter, vol. i, page 329 — " Fear will produce actions of involuntary parts, as 
purging, discharge of urine, &c." Whytt also observes, in saying that we know 
not how blushing occurs from mental emotion — " Sufficient it is, that we know 
from experience that the several parts of the body are variously aifected by the 
different passions of the mind." — Works, page 56. 



188 



tations. Ambition, for example, excites, and in a manner sustains, 
the energies of the reasoning faculties, for a time in an indomi- 
table continuity of action ; joy, on the other hand, rather opposes 
the severe exercise of intellect, wliilst grief cripples it, and renders 
it almost incapable of exertion. Another influence, equally remark- 
able, yet extremely difl"erent in kind, and perhaps of all others most - 
salutary, is that exerted by benevolence on the reasoning faculties. 

It has neither the excitement of ambition, the idleness of joy, 
nor the gravitating tendency of grief. The calm peace that an ha- 
bitual kindly feeling diffuses over the mind is peculiarly favourable 
to the exercise of our intellectual faculties. It produces a steady, 
forward movement, which not only allows of salutary alternations 
of rest and labour, but renders both equally sources of enjoyment. 
In thus traciug some of the links which form the chain of sympa- 
thy between mind and body, and between certain quahties of the 
mind with each other, I wish to impress that it is not a mere matter 
of ingenious or interesting speculation ; neither is it at all connected 
with any metaphysical subtleties. I only wish to speak of things : 
you may call them functions, manifestations, sentiments, propensi- 
ties, faculties, or what you please : I care not what they are : — they 
are things, occurrences, observable phenomena, which exert a most 
important influence on the body, the diseases incidental to which it 
is alike the business of my life to study, and my profession to re- 
lieve, and which, therefore, it is necessarily of great interest to be 
able to unravel to the utmost of my power. The means of reliev- 
ing diseases by sympathetic influences, or the discovery of these 
influences in their causation, can be obtained only by ascertaining 
the laws of their operation. It is certain that they have laws ; and 
it is equally so that we are in the very infancy of our knowledge in 
regard to them ; wliilst the very little that is known renders it pro- 
bable, and in my mind certain, that an increase of such knowledge 
will materially improve our knowledge of the treatment of disease. 

But to return to the sympathies. Nature, I think, would not 
have unfolded so much, nor have given us such a range of interest- 
ing, beautiful, and obvious phenomena, if there were any better 
mode of studying the phenomena of the body. It is our duty to 
observe these phenomena with our utmost vigilance, because all 
analogy, furnished by the experience of other sciences, shews that 
we shall be amply repaid. 

The general sympathy of the mind with the body has been 



189 



already mentioned ; but the examples of it would be but a host of 
truisms. 

We require to go beyond the general fact, and to get at some- 
thing like a knowledge of the various organs, whether bodily or 
mental, which are the sources of its exemplifications. I shall, how- 
ever, reserve the few words which I can add on this subject at pre- 
sent to the conclusion of that section which has for its object to lead 
you to some of the applications of the phenomena of sympathy. 



190 



DISCOURSE V. 

CONCLUDING REMARKS ON SOME OF THE USES AND 
APPLICATIONS OF THE PHENOMENA OF SYMPATHY. 

In the few illustrations wliich I have given of the phenomena 
of sympathy, you will have already acquired some general notion 
of their importance ; but you will probably have perceived but 
little, either of the extent or mode of their application. This 
cannot be entirely supplied by the remarks* which I have to make 
at present ; since the range of influence exerted by the sympathies, 
whether they are regarded as manifestations of health, as indica- 
tions of disease, or as hints from Nature as to how we should set 
about relieving it, can only be wrought out of a careful study of 
all the phenomena of a living body. 

In anatomy, we see arrangements admirably adapted to the 
purposes they are designed to serve ; and, from a natural, and in- 



* The subject of sympathy demands a work exclusively devoted to it. It is 
far more important than those who have not given the subject much reflection can 
reasonably be supposed to perceive. But the work would necessarily be a thick 
octavo volume at least ; and would probably not pay its expenses, unless undertaken 
by some one of very high reputation. The periodicals, however, might, I should 
conceive, take it up with advantage ; and, although I would not undertake the 
whole thing, I would be a cheerful contributor. The work should be conducted on 
an inductive plan ; so that, whether it produced any thing directly or not, it should 
be a real basis of further enquiry. It should embrace and commence with the 
sympathetic phenomena exhibited between any two separate existences of any 
kind whatever, and then proceed to the enumeration of those manifested by the 
various parts of the same individual. When the whole of such phenomena were 
brought together, including alike, corporeal, sensual, and mental, then those cir- 
cumstances which they, or any of them, possessed in common, should be stated, 
with the exemplification in detail ; nothing being assiimed, in this primary classi- 
fication, but what was obviously true. If this led to the development of any law — 
well ; if not, it would furnish, I conceive, the sound pabulum for further reflection ; 
leading to the next point, the physiology of sympathy, if the foregoing enquiry had 
not indeed sufficiently developed it; for the proximate use of phenomena is one 
thing, the law out of which they arise is another. 



191 



deed irresistible, analogy, we infer that the same excellence prevails 
in structures which are beyond our power of unravelling, as also 
in functions the nature of which may be beyond the reach of our 
perceptions. 

In the present limited state of our knowledge, we perceive a 
harmony and adaptation, in many instances, that is very intelligible 
to us. Tlius, many of those relations which the eye has to light, 
the ear to sound, the lungs to the atmosphere, are clearly intelli- 
gible. It is equally demonstrable, that things which are really 
useful to us are contributory to our pleasure, and that excess is 
hurtful ; that not only, therefore, is the supply of our wants secured 
to us by proper adaptation of various organs to our necessities, our 
localities as individuals, and to external nature, but that these 
wants are, in all animals, made vehicles for enjoyment ; that this is 
not only true of Man, and of the animals most nearly allied to 
him, but that it is equally the case with all animals, so far as our 
perceptions enable us to form any idea on the subject. 

When we reflect on the accomplishment of such objects, and 
the prevailing benevolence which characterizes them in such 
countless millions of every variety of shape, form, and habit, as 
the animal kingdom presents to us, we are quite lost in wonder ; 
and when all our feeling of this kind is, as it were, exhausted, and 
we begin to study matters a little more in detail, we are surprised 
to find that every thing of so complex a nature is, as far as we can 
understand, wrought through the instrumentality of organs whose 
mechanism is extremely simple ; so that we never arrive at a true 
ascertainment of their real use, but with an accompanying percep- 
tion of their extreme .simplicity. 

These contemplations naturally excite our admiration and gra- 
titude ; and so overwhelming is their vastness, that we are glad to 
turn from general views to the consideration of some one object. 
If this object be man, we soon find, even in this comparatively 
small arena, with how small and insufficient an instriiment he is 
furnished in the mind, when compared to the object on which it is 
exercised. Now nothing is more wonderful than his sympathies : 
from the foregoing reasons, we infer that they are of the highest 
importance, and that their laws are beneficial to him. For it mat- 
ters not whether we survey man as a mere animal, whether we 
regard the phenomena which he presents in general, or his sym- 
pathies only ; or whether we add those which regard him as the 
tenement of that extraordinary creation, his mind ; we shall find 



]92 



matter for interest at every step, for wonder in every function, evi- 
dence of intelligence in every fibre, and Omnipotence in all. 

The body, in its physical sense, has been compared to a ma- 
chine*, and, for purposes of illustration, often happily enough. I 
have sometimes endeavoured to explain to patients the real nature 
of a local disease, as it is called, by telling them that when the 
hands of their watches cease to move, they look for the cause in the 
general structure of the machine, that is, in the interior or works. 
We have no machine, however, with which we can compare the 
living body. In all that we are acquainted with, if they become 
out of order, they stop ; no part really connected with their essen- 
tial structure can be disordered but the whole machine ceases. 
The machine, as a motive engine, is dead, as it were ; but the case 
is w^idely different in the living body. There is no single organ but 
which may be exceedingly deranged, and yet the machine continue 
its movements. All the complicated phenomena of respiration, 
circulation, assimilation, absorption, secretion, excretion, — nay, 
thought, perception, comparison, judgment, — may go on, and yet 
there may be some very important organs seriously disordered, 
and perhaps partly destroyed. You know, indeed, that people die 
with diseased heart, or lungs, or brain, stomach, liver, &c. ; but 
the very mode in which you obtain this knowledge, shews you that 
they have lived with these diseases. How can all this be ? Are 
we to suppose that parts are formed larger than natural, in antici- 
pation of disease or partial destruction of them ? How is it that 
these changes are allowed to take place in their physical properties 
and functions, not only as regards the sustentation of life for a 
time, with impunity, but actually in many cases not incompatibly 
with enjoyment ? Now here we come to a point at which consi- 
deration unfolds to us one very important end, in the establishment 
of that sympathy between every part and every organ, which it is 
my object to impress on you. For it is by means of sympathy 



* The general objects of this volume do not allow me to enter at large into 
the physiology of the sympathies. I am only desirous of doing so much as 
is necessary to give you a general idea of their practical application, by the enu- 
meration of a few important principles. The more complete adaptation of them 
to different cases, belongs to the consideration of various diseases of which it will 
be my object, sooner or later, to treat in their respective places. So I have not 
discussed, at present, the sympathies evinced by the organs of sense, because these 
will be more impressively and usefully considered, when in a subsequent volume I 
have to treat of their diseases. 



193 



between parts, tliat that compensating action or actions take place, 
of which I spoke in the Second Discourse, and the tendency of 
which is continually to preserve an equilibrium. It is by means 
of sympathy, that an object of immense importance is achieved in 
the animal oeconomy ; and which is no less than this, — that no 
function, however important or apparently isolated from the rest, 
depends wholly on any one organ for its entire performance : and 
this preservative tendency of the laws of sympathy appears the 
more striking, in that the sympathies seem most lively, most gene- 
ral, or most easily excited, where they are likely to be most re- 
quired; that is, at the different avenues of injurious influences, 
or, as I have called them, the various portals of the body. The 
mind, the digestive and respiratory organs, the alimentary canal, 
lungs, skin, and urinary organs, are instances in point. It is ne- 
cessary, however, in teaching, that I should explain a little more 
fully what I mean by " no function depending on any one organ 
for its entire performance." This, physiologically considered, is 
quite true ; the assistance, however, is rendered in two ways, 
very distinct in manner, but the same in effect. Sometimes one 
organ will literally execute the entire function of another organ, as 
when one kidney performs the office of both ; sometimes it con- 
tributes to its performance, as happens between the skin and lungs, 
or skin and kidney : sometimes the assistance is rendered in an- 
other way, — that is, the relieving organ does not actually perform 
the functions of the organ to be relieved, but it gives it less to do. 
So that, whether the relief is rendered by an actual assistance in 
the task, naturally proper to the disordered organ, or by giving 
it less to do, the relief is equally true and substantial. Of the kind 
last stated, I will mention an illustration or two, for the purpose of 
rendering the proposition more clear to you. 

No organ can perform that part of the circulation which the 
heart does ; but as the force required of the heart is in proportion 
to the quantity of the circulating fluid to be continually projected, 
many organs can relieve its labour. In other words, the quantity 
of the circulating fluids is diminished, sometimes by the skin ; 
sometimes by the kidney ; always by the lungs ; and, occasionally, 
by the whole of these organs. There are other modes of sym- 
pathy also, which refer to the nervous system, equally interesting : 
I must not, however, attempt to follow out every principle, but 
must be content with familiar and easily intelligible illustrations. 
I will take another organ, however, because it is one which, from 

o 



194 



its importance, might readily suggest itself to you ; and about 
which, as exemplifying the truth of a rule which I have stated, you 
might have some difficulty. No organ but the stomach can per- 
form perfectly that process which it executes hi the digestion of 
food* ; but it is not less interesting to remark what happens in many 
cases where this most essential function is embarrassed. In indi- 
gestion there is nothing more remarkable than the loss of appetite ; 
the inaptitute, and, in many cases, the incapacity for exertion. The 
body can hardly labour, the mind works with great difficulty ; there 
is what we call listlessness and languor ; the whole body, being im- 
perfectly supplied with the pabulum literally necessary for its vital 
powers, becomes a niggard of their expenditure ; and yet, if a 
powerful volition determines the body to exercise, or to an expen- 
diture of power, in spite of these depressing inclinations, the di- 
gestive functions will again sometimes recover their powers. 
Nothing can be more beautiful than the pervading tendency to 
preservation, torture Nature how we may. A recurrence to the 
foregoing pages will furnish you with many examples of the preser- 
vative power through the compensating actions of the sympathies. In 
fact, every sympathy of the body presents evidence of this power ; 
and could we understand as much of it in all diseases, as we can in 
some, or as we can in states which may be regarded as health, or 
very sUghtly different from it, we should most likely make more 
progress by such a discovery in the treatment of various maladies, 
than we have yet done by the accumulated enquiry of ages. Nor is 
the application of sympathy at all new in the treatment of disease. 
Medical men have, at all times, been acting on disease in a mode 
which is alone explicable by the laws of sympathy. For example, 
a headache arises very often from disorder of the stomach ; you 
relieve the stomach of its contents, by an emetic, and the headache 
subsides. Now here the head was affected by one condition of the 
stomach, and relieved by another condition of that organ. 

So again, pain may occur in the head as a consequence of 
costive bowels ; we administer an aperient, and the head is re- 
lieved. Now I state two familiar examples of the action of sym- 
pathy in the causation, and in the relief of a common- disorder ; 
but any two organs in the body may afford similar phenomena. I 
wish you to recollect, that, in the examples above stated, a 



* This is genei-ally ti'ue, notwithstanding that, in certain cases, we contribute to 
the support of the system by the injection of nutritious matter into the lower bowels. 



195 



disordering impression has been conveyed from the stomach or 
bowels respectively, to tlie head, and the corrective, or impression 
induced by the emetic or aperient, has travelled the same route. 
Now, a great deal of the practical application of the laws of 
sympathy turns on the principle here mentioned ; and it has been 
applied, very largely, to the treatment of diseases, even before the 
phenomena of sympathy had been made the subject of any very 
express investigation. 

There are again other sympathetic phenomena, equally de- 
monstrable, which have not, so far as I know, been made that use of, 
of which they are clearly susceptible. Still, keeping to the most 
familiar instance which occurs to me, you know, perhaps, that 
disorder of the liver will frequently produce also pain in the head ; 
yet here, in many (^ases, an emetic will equally relieve the head as 
in the case wherein it proceeded from the stomach. Now this is 
something different*. The stomach, it is true, is disordered in 
these cases, as well as the head ; but the cause is an affection of the 
liver: yet an impression on the stomach relieves the liver as 
well as the head ; and thus the salutary impression travels back 
to the liver in a course retrograde, as it were, as regards the 
liver. But let us take another example or two of this kind of 
sympathy. Several individuals may be exposed to cold ; the 
effects on each may be very different. It may produce appetite, 
or occasion loss of it; it may give rise to vibratory actions of 
liQuscles (shivering), sickness, headache, and various other dis- 
agreeable symptoms ; yet food, or a glass of brandy-and-water, 
or perhaps even warm water only, taken into the stomach, may 
remove any or all of these sensations, notwithstanding that in some 
cases the stomach may be, and in others not at all, affected. f 

* The reader will of course bear in mind, that, in disorders in which the liver 
most prominently declares its disturbance, the cause may, nevertheless, have been 
in the stomach. But many disturbances of the liver, from cold, and from moral 
causes especially, do not allow us, with any reasonable probability, to infer that 
they have occurred from any intervening influence of the stomach. 

t I have endeavoured to explain, at some length, and, so far as I know, for the 
first time, in my work on the Sympathies, as applied to the " Unity of the Body," 
how cold, or catching cold, occasions the multiform and too often serious maladies, 
of which, in this variable climate, it is so common a precursor ; and to this I refer 
the reader. Dr. James Johnson, in his " Q^conomy of Health," glances at the 
affection of distant parts, 1 y the affections of the skin. I wish he had followed the 
principle out more fully. By the way, I would recommend that book to general 
perusal. It is written, perhaps, in a somewhat discursive style, and now and then 

o 2 



Now, here jou have an organ secondarily affected ; the sto- 
mach becoming the vehicle for the salutary impression which 
restores the equilibrium of our sensations; and, in some cases, — 
such as the shivering, for example, — where there is no evidence of 
its being affected at all. 

Again, every surgeon knows well enough the various affections 
of distant parts, produced by certain disorders of the bladder, kid- 
ney, &c. Of these, none are more remarkable than coldness of 
skin and shivering ; yet a warm bath not only relieves the skin, 
which is here secondarily affected, but very frequently the irrita- 
tion of the urinary organs, whence it has arisen. In many cases, 
Nature does this by a reaction, in which the shivering is succeeded 
by profuse perspiration. This is by no means, however, confined 
to affections of the urinary apparatus ; since an intermittent, 
which accompanies this, in common with so many other disorders 
of the skin, is but a succession of the phenomena to which I am 
adverting. Here we see again actions taking place in the skin, the 
organ secondarily affected, attended with relief, not only to itself, 
but also to those organs, from sympathy, with which its functions 
became originally disturbed. So, in patients who labour under 
phthisis (consumption), 1 have often seen them receive great relief 
from external warmth. 

But hitherto, with one exception, we have been speaking of 
relief being transmitted from one organ to another, when both have 
become affected ; though one may be primarily, and the other se- 
condarily disturbed : but it is very important to recollect, that it is 
by no means necessary to the relief of one organ, by means ad- 
dressed to another, that both shall have been affected. On the 
contrary, we may often relieve one organ by means addressed im- 
mediately to another, although that other shall have exhibited no 
indications of disturbance. We apply this principle most auspi- 
ciously when we make an impression on an organ, between which, 
and the one disturbed, there is the most direct and lively sympa- 
thy ; though even this, perhaps, is not always a necessary condition. 

a good argiuBent is weakened by a somevrhat light and not very clear mode of 
reasoning ; but it is, nevertheless, a very excellent work. It contains a great deal 
with which I for one would wish the public were familiarly acquainted, and to 
which I should be glad to find that the profession paid that attention which it de- 
serves. Besides much that is very sound in a medical and philosophical sense, 
there is a moral tone preserved throughout the work, which, though not always 
very flattering, is for the most part pure and time : and, lastly, there is a happy 
buoyancy of style which renders it very entertaining. 



197 



Exemplifications of this principle are common enough. Asthma, 
an affection of the lungs, and commonly of the heart also, is, we 
know, remarkably relieved by emetics and sudorifics, in cases 
where we cannot fairly demonstrate any material disorder, either 
in the stomach or skin ; the affection of the latter, of which I have 
just spoken, that is, coldness or shivering, is by no means a neces- 
sary condition to its affording relief to the urinary disturbance. 

This application of sympathy is nowhere, that I have hitherto 
found, more valuable than in the regulation of the bowels. A pa- 
patient may have torpid bowels (the bane of many a man's ex- 
istence) ; he shall take various kinds of aperient medicines ; he shall 
wash out his large intestines with injections ; but still, whenever 
he remits these artificial modes of proceeding, the bowels become 
again torpid. Now, he may have no detectable disorder of the 
skin, and yet, perhaps, on an impression being made on it by the 
warm or vapour bath, his bowels begin to act regularly ; or the 
medicines which were before hardly sufficient to procure a free 
alvine discharge once a day, become active purges, so that he is 
obliged to relinquish their use. I have known both occurrences 
take place. I do not say that the skin is the only organ through 
which this desirable thing may be accomplished ; for I have done it 
through other channels, — for example, the kidney ; — so that a 
diuretic has been administered internally, and with success, as an 
aperient, where aperients, commonly so called, had failed or proved 
troublesome. 

Now here we have opened to us a simple principle in relation 
to the treatment of one of the most obstinate maladies we know of ; 
namely, habitually costive bowels. I shall have plenty of oppor- 
tunities for illustrating this point ; but one case I am tempted to 
mention, because it occurred in the practice of another gentleman 
soon after I had first published some views in relation to this point, 
and by whom the case was kindly communicated to me. Dr. 
Green, of Marlborough Street, informed me that a patient called 
on him, to know whether he thought that a vapour-bath would be 
serviceable in removing a slight eruption on his face. Dr. Green 
was proceeding to make the necessary enquiries, when the gentle- 
man brusquely interrupted him, saying that he had had plenty of 
advice ; all he wanted was to know whether the bath would do him 
good. He took a sulphur vapour-bath ; and the next day waited on 
Dr. Green, saying that a most extraordinary thing had happened- — 
in fact, that he had had a natural evacuation from his bowels. As 
there appeared nothing extraordinary in this, he proceeded to in- 



198 



form Dr. Green that, some eight years ago, he had returned from 
India, in consequence of some complaint in his liver, and that he 
had continued a valetudinarian up to the present time ; that he had 
taken a great deal' of advice without success, his most annoying 
complaint being an inveterate torpor of the bowels, so that he was 
obliged to have recourse daily to an alternation of powerful aperi- 
ents, and to the additional help of injections, to procure a dis- 
charge ; that, for the last two years, he had been under the care of 
a distinguished surgeon, who had at length restricted his aperients 
to the alternation of four. I forget what they were ; but was 
amused with the mention of two of them ; namely, croton oil and 
a powerful quack medicine. These I mention as shewing the na- 
ture of the case. He took the baths daily for three weeks (Sundays 
excepted) ; and his bowels acted regularly every day without further 
assistance. It may be said that the sulphur here \vas an aperient, 
and that it acted in virtue of this quality ; but I am not disposed 
to attach much importance to this, chiefly because I have seen simi- 
lar results from vapour of w^ater only, and because it was not very 
likely that sulphur should have produced so much, especially such 
continuous effect, after almost every other medicine had failed. 
Besides, his bowels acted on the Mondays, when he had not taken 
the bath on the previous day ; and, lastly, they continued to act re- 
gularly after the bath had been wholly discontinued ; all which is 
reconcileable with an altered condition of the system, but is not 
reconcileable with the action of an aperient, in the ordinary sense 
of the word. This case was related to me by Dr. Green soon after 
he had perused my work on the Sympathies, as an illustration of 
the principles there enunciated. The case, however, is not singu- 
lar ; impressions on the skin generally having often very marked 
effects on the bowels, as has been previously mentioned. Dr. 
Whytt relates cases of dashing cold water on the abdomen having 
proved effectual in the relief of constipated bowels ; which is a 
different exemplification of this principle ; that is, of relief conse- 
quent on impressions made on an organ not detectably disturbed ; 
and of this I have also seen a very remarkable example. 

A very interesting case occurred to me, shewing the value of 
applying these principles. During the influenza of last winter, a 
gentleman, aged sixty-six, requested my attendance, whilst la- 
bouring under a very severe form of this complaint. His breath- 
ing was much oppressed ; his tongue very foul ; there was a 
copious expectoration, wliich he brought up with great distress 
and difficulty ; and he could not retain anything with certainty 



199 



on his stomach, vomiting occurring very frequently ; his pulse was 
excited, but not indicative of power. I gave him aperients, and, 
some hours after, a dose of calomel with antimony. The aperient 
produced discharges from his bowels, of which the calomel and an- 
timony seemed to promote the continuation. These discharges 
were literally black, and streaked with blood. The next day, how- 
ever, he was so entirely relieved, that I apprehended no difficulty, 
although an enquiry into his habits shewed them to be exceedingly 
unpropitious to his recovery ; and these habits his appearance re- 
markably demonstrated. I therefore enjoined him to continue his 
cautions till further directions were given him, and to take nothing 
but gruel and small portions of toasted bread. On visitiug him 
the next day, I found him just as bad as ever, and even weaker. 
I now found that, contrary to my directions, he had been rendered 
so incautious by his rapid amendment as to take, on the preceding 
evening, a glass of ale and a glass of brandy and water. He was 
now much alarmed. I repeated the mercury, &;c. as before, with 
no success. Notwithstanding that his secretions rather improved, 
they were still far from natural. He continued to sink : his sto- 
mach would retain neither food, medicines, nor wine, nor other sti- 
mulants ; which last were cautiously administered, as he appeared 
to lose strength so rapidly. His breathing induced great accumu- 
lation of secretion in the respiratory passages ; but he had no 
strength to relieve himself from scarcely any of such accumulation. 
I should have been glad, at one period, to bleed him, had I dared 
to do so ; but I could by no means procure any evidence that his 
powers would bear any reduction of this kind ; and now it was 
quite out of the question. His pulse was rapid and excited, but 
without even the semblance of power. Under these circumstances, 
I was determined to try whether I could not influence the condition 
of the mucous membrane of his lungs (apparently the immediate 
source of danger) by an appeal to the largest surface to which I 
could get access, between which and this membrane there is a re- 
markable sympathy. I therefore had him cautiously removed 
from the bed, put into a vapour-bath (steam-bath), and warm 
water, in large quantities, applied by injection to the mucous sur- 
face of the bowels. He was then put into bed ; and the effect 
was every thing that I could desire. He slept several hours ; he 
was quite a different person in the morning ; his symptoms had all 
undergone a most remarkable mitigation ; and, in three days, he 
was sitting up in his chair, comparatively convalescent. His skin 



200 



had acted profusely ; his breathing became nearly natural ; and, 
what was not less interesting, so did the secretions from his 
bowels. In a few days more, he was quite recovered. Now 1 
repeat that this was a man of sixty-six, a man who had indulged 
his appetite, and who was habitually addicted to the use of ardent 
spirits. 

In speaking, however, of the application of the principles of 
sympathy to the relief of torpid bowels, there are some other 
remarks which I am desirous of offering to your consideration. 

When we wish the bowels to act, we give purgatives; but 
many circumstances render it doubtful whether we endeavour to 
imitate Nature in this practice so closely as we should do w^ere her 
operations studied with more attention. When an organ does not 
act, there must be, of course, some cause for its inaction ; and this 
it is which it should be our endeavour to discover. Now, when 
the bowels refuse to act, it is quite clear that the reason cannot be 
because they have not the stimulus of jalap, scammony, manna, or 
other purgative medicines. The first consideration of the subject, 
as well as the history of the whole of the phenomena attending 
the administration of purgatives, shew^s most clearly that we, in 
general, remove effects without addressing ourselves to the causes 
of these effects. I grant that, until we extend our views by an im- 
proved mode of study, even this may be very useful ; that it often 
saves a patient's life, and must be done until we acquire better in- 
formation ; but that should be our unceasing endeavour. It is per- 
fectly compatible with the most enlarged perception of our present 
powders to study to improve them : in fact, a true perception of our 
ignorance is the first step to the accomplishment of this end. 

I say, then, that aperients are a poor substitute for the na- 
tural excitement. In the first place, do we ever produce a really 
natural discharge from the bowels by any aperient whatever ? 
The answer is startling, but it is true — never. Let any one, even 
not of the profession, consider this point, and he will soon see that 
there is always a manifest difference in the discharges from the 
bowels, when they act spontaneously and when they act under the 
infiuence of aperients. In the latter case, pain or uneasiness is so 
common an attendant, that we at length cease to regard it, or only 
think of it as, in some degree, a necessary adjunct to the action of 
aperients. But tliis is not really the case : by care and a judicious 
adaptation of graduated doses, in the manner insisted on by Mr. 
Abernethy, and especially if we take a lesson from those who ha^'e 



201 



the care of other animals, and give gruel or warm fluids, we may 
generally avoid pain ; but still the whole results manifest more or 
less of unnatural excitement. The evacuations are often fluid ; 
still more commonly pultaceous, and attended with more secretion 
than natural ; so that, in strictness, we can hardly be said to have 
it in our power simply to make the bowels discharge their con- 
tents*. But these are not the only evidences of excitement : almost 
invariably a state of torpor succeeds ; and this is so common — T 
had almost said universal — that, even when the bowels subsequently 
continue to act spontaneously, a day of inaction intervenes. This 
is a certain sign of factitious, as contradistinguished from natural, 
or at least healthful, excitation. Even those who are most troubled 
with costive bowels will often tell you that their bowels act readily 
enough when excited by aperients ; but that the moment they re- 
linquish the use of medicine, the bowels again become torpid. 
Now I press this point on your consideration, because it is but one 
head, as it were, of that Hydra which is the bane of medical prac- 
tice ; which is so often ministering to the effects, without looking 
deep enough to discover the causes, of disease. So universal, in- 
deed, is this kind of practice, that we may exemplify it wdth regard 
to any organ with equal truth. The stomach, perhaps, is the most 
common example, in the endless administration of tonics, and a 
variety of other agents, to which it is subjected ; and a very long 
catalogue of articles applied to disorders of the nervous system 
affords us a multitudinous set of examples of the same kind. How 
seldom is it that the powers of Nature are really fairly tried, until 
those of art, or science so called, have entirely failed ! How rarely 
it happens, that such simple, such obvious measures as alterations 
in eating or drinking, or change of air, are duly tested ! and yet so 
potent are they in various disorders, that the most striking, the 
most clear, and indispiitable proofs of their efficacy are derived 
from cases where all kinds of medical treatment have failed. But 
to keep to the bowels : I say that, when purgatives are administered 
for habitually torpid bowels, the evidence of excitement, the subse- 



* In our enquiries, it is often very important to ascertain the actual contents of 
the bowels, unobscured by any addition to them which aperients, exhibited with a 
^'iew to induce the ejection of their contents, may occasion ; and this where, not- 
withstanding, we may intend to employ aperients. To make this preliminary en- 
quiry, the administration of a common warm-water injection is, perhaps, the best 
mode of proceeding. 



202 



quent torpor, their almost universal failure in this class of cases, 
shew that thej do not, in one case in a hundred, minister to the 
cause of the malady. 

Now, 1 am not contending against their exhibition, in tlie present 
state of our knowledge ; but I say that we ought to endeavour, and 
that I believe we shall succeed if we do endeavour, to extend our 
knowledge on this important subject; and that I am certain that a 
very fruitful source of improvement is already to be found, as well 
as a still increasing knowledge in a careful observation of the sym- 
pathies. In one class of cases, we may perhaps be said to employ 
aperients, in approximation, at least, to a more correct principle ; 
and this is when we excite the secretion of bile, in costiveness, de- 
pending on a deficiency of that secretion : but here again that 
question, which we would hitherto moot with regard to the bowels, 
recurs in respect to the liver — what has rendered it torpid ? Was 
it because it was not stimulated by mercury, mineral acids, or any 
other of our probilious medicines ? Unquestionably not. We 
have no reason for supposing that the liver is naturally accustomed 
to any such stimuli*. Nature here again shew^s us that they are at 
best but poor imitations. The actions they produce are accom- 
panied by sensations which do not attend the natural action of the 
liver ; neither is the torpor of the liver, when habitual, reheved 
solely by any such measures. We are obliged to employ a variety 
of others, if we wish really to remove the malady. So, whether 
the bowels or liver, or any other parts, do not perform their func- 
tions, and you cannot discover, in the organ affected, the cause of 
the disturbance, you should examine the condition of all the other 
organs, and especially those between which and the disordered part 
there is a well-known or easily excitable sympathy. If the bowels 
were the part disordered, the skin, lungs, stomach, liver, and 
kidney, would first excite your attention. Impressions on all these 
organs will, in different cases, relieve costive bowels, when all other 
means prove nugatory ; of this I have, in my own experience, seen 
examples. As regards the lungs, nothing is more popularly fami- 
liar. There is notliing more common than to hear people say, that 
this or that place agrees very well with them ; that they have 
never any trouble with their bowels when they are there. It is 
true that, in these cases, several causes may operate ; but this is 



* I cannot too often impress the fact, that the seat of the disorder is one thing ; 
the seat of its cause another. 



203 



only another example of reacting by secondary causes on the origi- 
nal caase of the disorder. A man, exposed to the thousand and 
one causes of disease, in a crowded city, gets his bowels out of 
order and his mind disturbed. He goes into the pure air and 
quiet of the country, and his mind becomes tranquil and his 
bowels regular. For, whether the air of the country acted on his 
physical, or the peace, quiet, and change on his moral, constitution, 
the principle is the same ; it is that of acting on a part secondarily 
affected, in consequence of its sympathies with the function origi- 
nally deranged. Mental disturbance is, no doubt, a fruitful source 
of disordered bowels, as they are also constantly enough primary 
sources of mental inquietude. The most inveterate case of in- 
tractable bowels I ever knew, proceeded from a moral cause ; the 
liver having been first intermediately disturbed : but the bowels 
maintained their sluggish disposition, although the liver appeared 
to have been corrected ; still, however, not in the same degree. I 
consider the question of costive bowels so important, that I shall 
add yet a little more in regard to it. In looking to the causes of 
costiveness, we should consider of what the bowels are composed, 
and also in what their action consists. Now you know that they 
are of a compound structure ; that, externally, they have a serous 
membrane ; internally, a mucous membrane ; intermediately, they 
are muscular ; and that these several parts are united by cellular 
tissue : that they are also largely supplied w- ith nerves, vessels, ab- 
sorbents, and all the apparatus of a high vitality. Now the proxi- 
mate cause of the ejection of their contents is, undoubtedly, their 
muscular action; and its absence, of their torpor. There are many 
conditions under which muscular parts act weakly, inefficiently, or 
not at all ; and this happens also to the bowels : but this influence, 
whatever it is, may operate directly on the muscular structure ; or, 
mediately, through its mucous, serous, or even cellular, contextures. 
But, again, the muscular coat only derives its power from the 
nerves ; and we thus readily understand how its functions become 
influenced by a multitude of causes not to be found in the part 
itself^ but which arise from the sympathetic connection which ex- 
ists between all parts, and especially, perhaps, between parts of 
similar structures. Now this sort of view, with regard to the mus- 
cular coat of the intestines, suggests to us the probability, at least, 
that it may participate in any general condition of the muscular 
system ; and shews us, therefore, something like an explanation of 
that which frequently enough happens, namely, the correction of 



204 



torpid bowels by means very different from our aperients. It ren- 
ders intelligible how bark may regulate the bowels in one case ; any 
means which improve the general health in another ; and, in some 
rare cases, even opium. But, again, the muscular coat will sympa- 
thize with its more immediate connections ; we see, in fact, that it 
does. If the peritoneeal covering be inflamed, the bowels refuse to - 
act ; and the real aperient here is the subduction of inflammation. 
An opposite effect will take place from irritation of the mucous 
surface, and the muscular coat will act inordinately ; but the cor- 
rection of this is the removal of the irritation of the mucous 
lining. 

I have known the bowels, in a case of great difficulty and deli- 
cacy, regulated by bark more successfully than by any other medical 
means ; a strict regimen accompanying it : and improvement of 
the general health, air, and exercise, are too familiarly known to 
achieve the same object, to require that I should cite examples. 
The induction of the action of the bowels by opium is more rare ; 
wherefore I will cite an example or two. I recollect a very severe 
case of enteritis in which every thing failed ; until at length a phy- 
sician (Dr. Lidderdale) prescribed opium, on which the bowels 
acted ; and the patient's life appeared to have been saved by it. 
In a case of diabetes mellitus, in the fourth volume of the Tran- 
sactions of the College of Physicians, by Dr. Warren, the patient 
took four grains of opium ; at flrst every night, and subsequently 
every second night; and it is remarked, " as curious," during the 
latter period, that the bowels acted better when the opium was 
administered than when it was omitted. I mention this, as shewing 
that inaction of the bowels depends on a variety of circumstances ; 
and that the mere absence of their mechanical functions, though of 
course the 'proximate cause why their contents are not discharged, is, 
in fact, not the true cause of the disorder ; and that, when we admi- 
nister stimulating or irritating matter to the mucous surface of these 
viscera, we are but administering to proximate, and indeed secon- 
dary, causes. In some cases, as has been already shewn, the laws 
of sympathy not only allow of this mode of proceeding, but, by 
reflecting back salutary instead of disturbing impressions, do truly 
act on the real causes of disorder. The true value of this prin- 
ciple, however, consists in the superaddition which it forms to the 
plan of attacking organs primarily affected when this cannot be 
managed or proves unsuccessful, not as standing in precedence to 
it. Purgatives, you know, are often administered with very differ- 



205 



ent intentions than those of merely evacuating the contained mat- 
ters*, and very necessarily ; but I am not discussing that class of 
cases. I am here only speaking of habitually costive bowels, in 
relation to the mode in which men set about relieving them, and 
desirous of impressing on you, as one very important application 
of the sympathies, that the state of the alvine function usually de- 
pends not on any condition of those organs abstractedly considered 
(mechanical obstruction, of course, apart), but on some condition 
impressed on them through their sympathetic relations, either with 
the general state of the nervous system, or with the condition of 
some particular organ : that the discovery of this is most readily 
made by considering the various organs of the body in relation to 
their sympathetic connections ; and that this will often enable us, 
by very simple means, to do more towards correcting habitually 
torpid bowels than all the aperients in the Materia Medica. To 
this object I limit my observations at present ; plenty of oppor- 
tunities will hereafter occur for considering and illustrating this im- 
portant subject more fully. 

The following case may be mentioned as illustrating the fore- 
going and some of the subsequent observations : 

Sarah Jones, aged forty-two, 13 Water Court, Islington, a pa- 
tient in the Finsbury Dispensary, applied for relief on account of 
the following symptoms : she has lost her voice, not being able to 
speak otherwise than in a whisper. She attributes the loss of her 
voice to getting wet in the feet, almost five months since, her 
bowels being at that time costive, which is her general habit. Her 
catamenia have ceased rather more than two months ; her bowels 
are costive ; her tongue yellowish- white. Her gums are much 
elevated, and highly vascular ; her urine scanty, but clear. Her 
skin acts every night in an unusual manner : she describes herself 
as being bathed in a most profuse perspiration. Mr. Leigh and 
myself agreed to try first what stimulating the kidney would do, 
since, she being able to go about her business with such important 
functions imperfectly executed, or actually suspended, it seemed 
probable that the profuse action of the skin was the source of im- 
munity from more serious ailments. Taking, therefore, the hint 
thus afforded, we proposed to make the kidney participate more 



* In cases where the object is to diminish the circulating fluids, the large se- 
creting surface of the alimentary canal presents a powerful engine in aid of such 
a purpose. 



2U() 

tlian it appeared to do in the excreting function. In order to keep 
the reasoning as close as we could, we simply gave her a diuretic, 
the nitrate of potash. In three days, she came and surprised us not 
a little ; in the first place, by speaking in her natural voice. She 
said that the medicine had produced more water, and natural in 
appearance, but that her bowels had also acted very freely ; and, - 
on the occasion of the second action, the catamenia had returned. 
The profuse night-perspirations, she said, she had " quite lost." 
We kept her under our care about a w^eek longer, during which 
she remained quite well. Surely nothing can be more beautiful than 
the simplicity of this case. 

The study of the sympathies, then, discloses to us this very 
important fact, — that salutary influences may be impressed on an 
organ, either directly or through the medium of any other organ ; 
and that there is no one particular course, between any two organs 
of the body, which is to be regarded as a necessarj' condition to 
the conveyance of such salutary impression, That, if the liver 
affect the stomach, you may correct the stomach by means ad- 
dressed to either organ ; or even to a third, in some cases, which, 
so flir as you can see, is not at all affected, provided that there is a 
ready sympathy between that third organ and either of the two 
others : and this is as true, mutatis mutandis, of any two organs in 
the body, as it is of the stomach and the liver. 

I say you may do this ; I do not say that you always can, be- 
cause we find that there are plenty of disorders which we cannot 
correct : but that which I am anxious to impress, is, that the fai- 
lure does not depend on any law of sympathy as to this or that 
course being essential to the conveyance of salutary impressions. 
What Mr. Hunter terms reflex sympathy, and which he exempli- 
fies in the feeding of the polypus*, that which had been still more 
strikingly exemplified by Dr. Whytt, in the experiments which 
have been mentioned, and that which has more recently excited the 
attention of Dr. Marshall Hall, though valuable and correct, seems 
only a part of the subject, as I would have you to understand it. 
I care not indeed how it be explained ; for it is with the facts that I 
wish first to deal. I'herefore, whether the brain, spinal marrow, or the 



* " The stomach first sympathizes with the whole body when it (the polypus) 
wants repletion ; and afterwards, by a reflex sympathy, the body is called into 
action, and its little arms extended," &c. — Hunter's Works, by Palmer, vol. i, 
j^age 328. 



207 



nervous system of individual organs convey impressions from and 
to them direct, or through the medium of the great nervous centres, 
it is unimportant. 

The fact to be remembered, is, that all sorts of impressions, 
whether disturbing or tranquillizing, may be conveyed from any 
one organ to any other without regard to direction ; and that 
nothing short of this view will enable you to combat disease on 
that vantage ground, as compared with ordinary practice, which a 
constant and due regard to the laws and phenomena of sympathy- 
supplies. - 

If a patient have indigestion, which has continued in spite of 
tonics, plain diet, exercise, and pure air, the foregoing principles 
would be thus applied. I try if I can influence his stomach by his 
sympathies. I am ignorant, perhaps, what organ may be tried with 
best chance of success ; but 1 direct my views to those with which 
observation and experience convince me the stomach has a marked 
sympathy. Well — I will suppose that I address the skin, as this 
is common ; and I make him clothe warmly, especially the feet ; I 
order the flesh-brush, warm or vapour baths, or I produce some 
irritation on the surface ; I employ these and many others which 
might be mentioned, singly or more or less in combination : and 
now the stomach has become calm, which had been fidgety or irri- 
table before, and that too without tonics or perhaps any other 
medicine — now I can tell you that, if you are analytical in your 
examination, and assiduous in your attention, you will meet with 
many cases of this description. 

Or suppose the disorder be of the liver, and every ordinary 
means fail — that mercury, the mineral acids, and other things, 
usually excitants to the liver, prove unsuccessful — or, what is also 
common, not only fail, but disorder the oeconomy of the system. I 
know that the skin, the kidney, the bowels, and the mind, sympa- 
thize with the liver as M-ell as the stomach. I address myself to 
these organs, either simply or in conjunction, as the particular case 
may suggest ; and the disorder is corrected. Now here again you 
will often succeed where your probilious medicines, commonly so 
regarded, have failed, or proved injurious. Now I hear some 
learned critic say, " Well, we want no ghost to tell us this ; we do 
this, although we may not always be aware of the plan on which 
we are acting." Very good ; I wish to put the most trite exem- 
plifications I can of the principles I am endeavouring to teach ; 
because, when the extent of their application is unfolded, in relation 



208 



to the treatment of particular diseases, the siiperstnieture on the 
foundation I am now laying will be as intelligible and easy as I am 
inclined to think it important. 

I must, however, bring this part of our business to a close ; 
but I cannot do so without a remark or two on the application of 
the sympathies, in relation to those which exist betw^een the mind ' 
and the body. No one doubts of this sympathy ; nor does any one 
dispute, that, in disorders of the mind, induced by physical disturb- 
ance, mental quietude produces a very salutary reaction on the 
bodily disorder : or, if the mind be primarily disturbed, that care and 
moderation of the bodily ailment not only very much modifies its 
extent and severity, but also reacts favourably on the mind. But 
I am convinced that careful investigation will enable us to make a 
very much more powerful application of these phenomena than we 
have hitherto achieved. For, at present, our treatment of the 
mind, in relation to physical disorder, consists of what appears to 
me to be a very coarse generalization, being limited in general to 
abstinence from undue exertion, avoidance of painful impressions, 
and the like. Now let us examine this point a little. If it be 
true that the mind be more or less affected by different organs, 
and again differently in different cases, which we know to be 
fact ; it seems, at all events, very unreasonable to expect much 
benefit from a treatment essentially the same in all. For if 
there be still those who (notwithstanding the evidence afforded 
by the very striking analogy of the five senses, by the nei*ves 
of motion and sensation) still feel a difficulty in ascribing dif- 
ferent functions to different portions of the nervous system or 
different parts of the brain ; yet they must admit that the sympa- 
thy shewn between the mind and body, is shewn in very different, 
and even in very opposite, modes ; and, whenever the mind is, so 
far as we can see, primarily affected, that its manifestations of dis- 
turbance are very different in different cases. In our appeals, 
therefore, to the mind, when suffering from disease of the body, to 
have only one mode of treatment, or one not essentially different 
for all cases, appears as unreasonable as it -would do were we to 
treat every lunatic in the same manner. 

Nothing can be more varied than are the manifestations of the 
mind in its sympathy w^ith the body. Here again I mention pur- 
posely those which are most trite. In one man we have cheerful- 
ness and hope beaming to the very last ; in another, a settled 
gloom and despair from the commencement : in one we have a 



209 



subdued tone and a prevailing kindness of feeling ; in another, a 
sustained irascibility. In one, fear of want, and an active principle 
of avarice, who shewed no such disposition before ; in another, 
habitual distrust of those in whom previously, and naturally, he 
had been accustomed to place most confidence. Neither are the 
intellectual functions disturbed in modes much less varied. Some 
individuals have individual perceptions disordered, some their 
powers of combination, and almost all suffer more or less of a ge- 
neral inefficiency in the particular pursuits to which they have 
been accustomed. In fact, the manifestations are exceedingly 
varied, and the illusions just as different as those presented in dis- 
ordered conditions of the external senses. And as the eye has 
illusory vision, the ear illusory perceptions of sound, so have we 
illusions as diversified in the mental perceptions*. And I cannot 
see that we have any right to presume that phenomena, so different 
as these are from each other, whether in their natural or diseased 



* I have spoken of different organs, and of different functions and faculties ; 
and I have no doubt myself, that different parts of the brain do exercise different 
functions ; since, putting aside what has been done by phrenological investigations, 
all analogy is in favour of this view ; whilst I know of no single argument which 
can be urged against it : but it is very immaterial to my argument, how the dif- 
ferent faculties are set in motion, abstractedly considered. Suppose that, in a 
given case, I found that a principle of avarice were the feature of disturbance 
and that I had reason to beUeve that it originated in, or maintained a disturbance 
in, any bodily organ, as the liver ; my object would be the same, whether the 
morbid manifestation was regarded as resulting from the brain generally, or from 
some particular portion of it. The main fact for me to know in the moral treat- 
ment of the case is, the impression vsdth which I have to deal, and that the object 
is to remove that impression. Now, if the means proposed were the remedies 
solely of a medical kind, it might be one thing ; but as this is not the case, it 
matters not to me whether the part of the brain in which the disturbed organ was 
seated, was at the side, the vertex, or the base, or pervaded the cerebral struc- 
ture generally. In a more advanced state of knowledge, this might be different ; 
and I believe the phrenologists do some of them apply remedies to particular dis- 
tricts. I have said enough already to shew what I think as probable in regard to 
this subject ; but I do not wish that the observance of demonstrable, and, in fact, 
well known phenomena, should be encumbered with anything which may be re- 
garded, as yet, as theoretical or speculative ; nor that simple facts should have 
their just importance merged in the consideration of the principles on which they 
may or may not depend ; which, by diverting attention, may tend to disjoin them 
from the useful and obvious conclusions to which they lead. For that avarice, the 
example chosen, will disturb a man's body, and that certain bodily disorders will 
engender an activity of this principle or sentiment, are truths which rest on (he 
indisputable authority of universal observation and experience ; and which are 

P 



210 



state, should relate to one and the same physical locality, any more 
than we should have to presume that sight is conveyed by the au- 
ditory nerve, or sound by the retina, which we know cannot be. I 
am disposed therefore to doubt wdiether, if we could understand 
more of this subject, — and I see no reason why we should not, if we 
try (since a more careful observation of phenomena is the thing 
required), — we should not find that some of our general measures 
for tranquillizing the mind are much on a par with that of the 
quack who cures all possible diseases by one remedy ; and as far 
from the mark as we should be, were we to attempt to relieve the 
eye by silence y or the ear by exclusion of light. In one point, there 
is a striking analogy in all mental and bodily disorders, whether 
coexisting or not, — viz. that they have one feature in common — 
the loss of equilibrium between the various organs. Some one 
organ does too much or too little ; and it seems a whimsical way of 
meeting this condition, by giving all the organs a general repose ; 
for change of scene, absence from exertion, cheerful employment, 
though excellent in their way, appear but coarse generalizations. 
They imply no analytical enquiry into the particular function, 
primarily or sympathetically disturbed, much less any special aid 
to it, at which we can arrive only by such analysis. The analysis, 
I think, would often enable us to understand the particular organ 
or function of the brain which was disturbed, and conduct us to 
more true and precise principles in our endeavours to make it 
react favourably on the bodily disorder, or to relieve it (I mean the 
mental disturbance) according as it might have been primary or 
secondary. Suppose that a man thought himself abandoned and 
worthless, that his friends were unkind and faithless, I conceive 
that anything which strengthened his self-esteem would be a judi- 
cious appeal to his disorder. This, perhaps, might be done by 
engaging in some schemes, no matter whether of study or occupa- 
tion, where his success might be rendered certain ; and by judi- 
cious doses of encouragement and approbation. So, if a dread of 
want, and a morbid superposition of a principle of avarice, were 
the leading feature ; and those I am alluding to are the most com- 
mon ; I conceive that a factitious activity, however induced, of 



neither shaken on the one hand, nor confirmed on the other, by the physical con- 
nections of that principle ; whether that be in the general mass of the brain, or 
any particular part of it, or neither, were that conceivable, this question has ob- 
viously nothing to do with the simple fact at issue. 



211 



any opposing propensity, would be the judicious mode of pro- 
ceeding; — as, for example, if we could lead him to any act of 
successful benevolence, or successful enterprise in regard to any 
object not ministering to avarice. I cannot, however, enter on so 
vast a subject as the manner in which these things should be done ; 
I am only here anxious to illustrate what I mean. The subject is 
one of great difficulty, and perhaps surgeons have scarcely as 
good opportunities of cultivating it as some other classes of the 
profession. I am well convinced, however, that the laws of sym- 
pathy might be rendered much more available in relieving mental 
disorder ; and, what is more to my purpose, through it, disorders of 
the body, were our examination of the particular sympathetic re- 
lations of various mental and bodily functions as assiduous, as our 
conviction of their general sympathy is unqualified. The con- 
clusion above stated appears to me irresistible ; because we know 
that different functions of the mind sympathize in different disor- 
ders of the body ; and also, from the repugnance which the mind has 
to admit, or indeed conceive, that disorders so manifestly different 
can be relieved by the same, or nearly the same, I'emedies : 
besides, I believe that, in the treatment of the insane, some ap- 
proximations like these are really kept in view ; and I cannot see 
why the principle of treatment should be less accurate in disorder 
of the mind, resulting from disorder of the body, than when it 
occurs from moral causes ; to say nothing of those cases of in- 
sanity, a very large number — I had almost risked the word, propor- 
tion, — to which bodily disorder so materially contributes, or which 
it entirely occasions. 

But if the mind, being primarily affected, disturb some bodily 
organ, and this organ be ascertainable, how are we to set about 
relieving it in cases where we have no means of relieving the 
cares and anxieties of the mind, whether natural or factitious ? 
since change of air, scene, or diversion, suspension of ordinary 
occupation, &c. which are occasionally in our power, though ex- 
cellent remedies of their kind, are, as we know, too often un- 
availing. 

Where this happens, it is very important to be impressed with 
the fact, — that the same law which allows any organ, primarily 
disturbed by the mind, to react on the mind, and thus increase the 
disorder of which it is itself the offspring, allows it also to become 
the channel of tranquillizing influences. Impressed, I say, with 
this fact, we no longer abandon the valetudinarian, whom we know 

P 2 



212 



to be labouring under depressing moral causes, to the chronic and 
uncertain influence of time, but endeavour to influence his miiid 
by care and correction of bodily disturbance, in the same manner 
that his body has been unfavourably affected by his mind. Now I 
could mention a great many examples of the application of this 
principle ; but I will select the following ; not because it is the ' 
best in immediate application to the point under consideration, but 
because, altogether, it is very strongly marked in other respects. 
K gentleman applied to me, who represented himself as a great 
valetudinarian : a state of infirm health, of some years' duration, 
had been attended by several attacks of illness ; for these, reme- 
dies of a powerful nature (calomel chiefly) had been resorted to, 
which again restored him to his ordinary condition, but which was, 
as I have observed, that of a valetudinarian. 

At all times, his distressing symptom was a lowness of spirits, 
accompanied by a very remarkable and uncontrollable tendency to 
melancholy retrospection. So inveterate was this tendency, that 
notliiug had proved sufficiently powerful to divert him from it ; 
although, on one occasion especially, an entire change of scene, 
with occupation on matters of great interest to him, had been in 
simultaneous operation. I found him an acute, well-read man, 
with something of a scientific turn besides. In answer to my va- 
rious enquiries, he told me that he scarcely remembered that he 
had ever been free from a tendency to retrospection ; and that he 
regarded a peculiar degree of this as natural to him ; but that its 
increase and constant presence, and also much of the melancholy 
by which it was accompanied, were certainly, though of many 
years' standing, subsequent superpositions. I found his body in 
bad order generally ; but it appeared to me clear, that his liver 
was chiefly, and, as I thought, probably primarily disordered. 

I should mention that, at the time his family induced him to 
consult me, his sjTuptoms had become so exacerbated, that they 
were under seiious alarm as to his safety ; and a hint was thrown 
out that somethhig had occurred w^hich justified the most melan- 
choly apprehensions. At our first conversation, he expressed him- 
self willing to follow any plan I should propose, provided that I 
really thought it would be of any ser^dc-e to him. As he put this 
very strongly, and desired me to be candid, I answered him without 
the least reserve. I told him that, if he would cordially co-operate 
with me, I thought I could materially improve his present condi- 
tion ; but that the history of his case (which his family had con- 



213 



lirmed) rendered it impossible for me to say to what degree. " I 
am of opinion, sir," said I, "that the disorder of jour bodily 
i'unctions, and of jour liver especially, are sufficient to account 
for a great deal of the mental inquietude under which you labour ; 
and that the augmentation of it which you have suffered of late 
years may perhaps be wholly dependent on such disorder ; but, 
unless I could discover how much of this increase of mental dis- 
turbance may have been induced by your bodily disorder, and how 
much depends on that increase of your natural disposition, the re- 
sult of time and indulgence, — and I can do neither, — so cannot I say, 
nor speculate safely on, the degree of advantage which you may 
derive from any plan that I can propose ; but whatever of your 
mental may arise from your bodily disorder I think you may rea- 
sonably hope to be relieved from." He seemed pleased with this 
mode of putting it ; and agreed implicitly to follow a plan, of which 
the following is the substance : I first well cleansed his bowels by 
graduated doses of aperients, and then endeavoured to regulate their 
action and their secretions, which were both wrong : his stools were 
very dark or black, and foetid, and his tongue very foul. His diet 
was strictly regulated ; and, as he could not refrain when in society, 
I reluctantly ad\T.sed him for a time to give it up altogether, that of 
his own family of course excepted. I ordered him to begin gradu- 
ally with daily horse exercise ; and, that he might have some ob- 
ject in so doing, and at all events sleep in good air, I made him take 
a house in the country. A very careful consideration of all circum- 
stances induced me not to prohibit his attention to business ; so 
that he rode backwards and forwards to town, except when the 
weather was unfavourable, when he was either to spend the day in 
the country or come to town in the coach, as suited his choice or 
convenience. I tried to solicit regular action from Ms liver ; but I 
was very cautious with regard to mercury, generally trusting to 
aloetic medicines, with occasional small additions of that mineral. 

The medicines, however, required occasional modifications ; 
and, with the exception of that above stated, his liver was gene- 
rally solicited by applications to the lowels, every care being taken 
to avoid giving pain or more medicine than was adequate to induce 
their action. With this sort of treatment, his secretions became 
natural ; his stools became indicative of healthy biliary secretions ; 
his urine, which had been dark and cloudy, became clear and natu- 
ral in colour ; and, lastly, what was better than all, his tendency to 
melancholy retrospection entirely left him 



214 



This case, though a comparatively recent one, made a deep im- 
pression on my mind, and the more so, as it occurred a short time 
previously to a very curious case, which was related in my hear- 
ing, of a patient who laboured under a very peculiar state of mind, 
which had led to self-destruction ; the patient having a voracious 
appetite, and having been allowed to indulge it to such an extent, 
that his consumption of meat had been six mutton chops a day. 

Now it appears to me difficult to conceive a case more unpro- 
mising, as regards the complete removal of the mental disturb- 
ance, than the one which I have related ; since it would be a very 
hazardous and bold presumption to say that the w^hole of it was 
the result of bodily disorder ; yet w^e see the removal of a morbid, 
peculiar, and very dangerous moral disturbance removed by mea- 
sures which certainly appear to have influenced the mind through the 
correction of the functions of the body. 

The phenomena of sympathy shew that the whole mind may in- 
fluence the whole body, or diiferent organs of it ; and that disorder 
of the whole body, or of different organs of it, can affect the mind, 
either generally or in some particular one of its functions : it seems 
to follow, as a necessary consequence, and in fact but as part of the 
same proposition, that, in particular cases or in particular persons, 
certain organs of the mind may affect certain organs of the body, 
and }'ice versa ; and hence it follows that our powder of applying 
these facts in the treatment of disease will be, cceteris parihus, in 
proportion to our know^ledge of the reciprocal sympathies between 
certain bodily and mental organs or functions. 

That investigation of the phenomena promises an approxima- 
tion to a more perfect knowledge of their several relations, seems 
probable, from some preferences between certain mental faculties 
and bodily organs being already so exceedingly obvious ; and, if 
we carry with us, in our investigation, the recollection that, in a 
strict conformity with what appear to be the laws of sympathy, 
w^hilst one faculty may, in a general sense, hold a more vivacious 
sympathy with one organ than another, yet that individual peculi- 
arity may give rise to great variations in this respect, we shall have 
the chief elements necessary for the investigation in question. In 
this w^ay we maj- possibly arrive, at no distant period, at much more 
direct and certain modes of restoring mental tranquillity, whether it 
be solely with reference to mental disorder, or with a view to make it 
act sympathetically in the relief of the body, when we discover 
and attack the condition of a particular organ, instead, as in some 



215 



other cases, where our ignorance of the key to the malady obKges 
us to be satisfied hy a sort of general avoidance of influences which 
are held to be injurious. 

Before I conclude the subject of Sympathy, there is one other 
subject in connection with it, on which I will add a few remarks, — 
and this relates to the facility with which it explains the connection 
of local diseases with states of the general system. Many persons, 
who are ready enough to admit the influence of general states of 
health, or of particular functions with local diseases (and, in their 
use of this term, they generally limit it to diseases as seen on the 
surface of the body,) feel a great difficulty in understanding how 
this can be, in cases where the local disease is influenced by local 
treatment, especially where their endeavours, by means directed to 
the general system, have failed. In the first place, I must endea- 
vour to dispel certain erroneous notions, or idols, which exist in 
regard to this subject, before I can hope to explain the matter ; and 
especially that frequent connection of the term * local disease' with 
actions at or near the surface of the body, which is evidently an error ; 
for no reason can be shewn why a disease near the skin should ne- 
cessarily be more local than when seated in any other part. But 
the truth is, that, in the sense in which the term is used, there is 
no such thing as a local disease, or a disease whose relations are 
confined to the seat it occupies. Injurious influences, acting on 
any organ, as the brain, lungs, stomach, or (what tends to puzzle 
people still more) the skin, may produce impressions and actions in 
the part, which action may confine the disordering impression, and 
the processes for its removal, to the part in question ; and, so far as 
we can perceive, this order of occurrences constitutes the purest 
notion we have of a local disease, whether it occur on the surface 
of the body or in any other organ. But this is very little, in fact 
nothing, in aid of the supposition of local diseases; for we 
know very well that this power in any part to correct, or in any 
way to dispose of, an injurious impression, depends on certain 
conditions of the whole system. It matters not, as an abstract 
consideration, what these conditions are ; but that they exist is as 
demonstrable as any thing in the whole range of natural philosophy. 
In many cases, they are demonstrable in their influences on local 
actions, both in suspending salutary processes, in creating them 
when they exist not, and also in the original production of diseases 
which render them necessary. I shall enter more fully into this 
subject hereafter, when I shall have to speak of diseases of the 



210 

skin —one of the strongholds of error. Bat I will not leave the 
matter wholly nntouched on the present occasion, as far as illus- 
trating the application of sympathy to the understanding of the 
question. 

We will take, then, on the present occasion, the purest example 
of local disease we can find, and the most glaring instance of what 
is emphatically allowed to be a constitutional one ; and, in both, 
we shall see that the sympathy of the whole body, or of any 
organ with all parts of the body, explains the phenomena. Now 
a man has a compound fracture that is, in itself, local ; but we find 
that the processes of repair actually depend upon the state of the 
whole body, just as certain as any constitutional malady whatever : 
they are, in various cases, accelerated, suspended, or wholly put a 
stop to by very demonstrable conditions of the whole economy ; 
yet, on the other hand, local influences are equally capable of 
effecting these objects, and hence the necessity of avoiding them 
by quietude, regulation of temperature, and so on. Now gout is a 
malady depending, on the other hand, altogether on the state of the 
body : this condition is no less real because it is varied ; nor does 
it produce gout less certainly than the accidental force did the com- 
pound fracture. Yet here again, in different cases, regulation of tem- 
perature, warmth, or friction, is not only productive of comfort, as 
regards the part, but have a beneficial influence in tranquillizing 
the general condition, of which the gout is the manifestation. Now, 
as the laws of sympathy teach us that salutary, as well as disordering, 
impressions can be conveyed from part to part, without regard to 
direction, they remove any difficulty in understanding this and a 
thousand other similar phenomena ; much less do they impel us to 
the absurd expedient of arguing, from such occurrences, that the 
diseases are local. I have taken two very extreme examples on pur- 
pose ; for you will find that these really include the facts on which 
the supposition of local diseases is founded. In many aflbctions of 
the skin, local applications do good ; and I have heard, very lately, 
this argument made use of to support their local nature ; but again 
the same mode of reasoning applies ; viz. that as local diseases can 
react on the state of health which produced them ; so any thing 
which soothes their actions, or in any way prevents their reacting 
influence, will do good. Then again, some diseases are cured by 
local remedies alone. Although it seldom happens that this is, 
strictly speaking, the case, yet here again the laws of sympathy ex- 
plain the matter ; since you are to regard the local malady but as 



217 



a channel of communication with the disordered body. The action 
oF narcotics, arsenic, lead, and a multitude of other medicines, 
illustrates this. It should be remembered that many local diseases 
are the expenditure of diseased actions : they are the relief that 
Nature herself affords ; aud they will often get well without any aid 
from art whatever ; whilst, where they do not, we feel (without 
exception in my experience) that this particular class of local ma- 
ladies is maintained, because the original disturbing impressions, of 
which the local malady is the result, are allowed to be in continued 
operation. The various kinds of porrigo, many examples of ulcer- 
ation in the legs, are, in many patients, illustrations of these posi- 
tions. But this is a subject which will be discussed more fully on a 
future occasion : I can scarcely touch on it here ; it is too vast, 
both in the facts connected with it, and the error which surrounds 
it, to be grappled with otherwise than as a distinct subject. 

To place, then, the facts derivable from the consideration of the 
phenomena of sympathy, in a sort of tabular arrangement, which 
shall, at the same time, assist you in recollecting them, or in re- 
freshing your memory by a table for ready reference, I present you 
with the following catalogue of conclusions : 

1. Any disorder disturbing the general economy may affect, in 
a particular degree, any organ or any tissue in the body. 

2. Any disorder or injury, primarily affecting any particular 
organ or any particular tissue, may affect the whole body. 

3. Any organ, primarily affected, may affect any other organ in 
an especial manner ; but the organs so secondarily affected will be 
different in different cases and in different individuals. 

4. That, in investigating the conditions of organs sympatheti- 
cally or secondarily disturbed, we may expect that continaity of 
surface, contiguity of position, commu.nity of structure, and con- 
currence of function, will be the chief circumstances by which our 
enquiries will be auspiciously directed. 

5. That, notwithstanding the foregoing, neither continuity, con- 
tiguity, nor community of structure, nor concurrence of function, 
are absolutely necessary conditions, individual peculiarities giving 
rise to sympathetic actions independently of these conditions ; 
which (though we may not be able to discover the law) are not the 
less demonstrable in their phenomena. 

6. That the phenomena presented by organs apparently prima- 
rily affected, are generally those most important and prominent, 



218 



yet that we can by no means establish such a rule ; for, whilst 
many organs, apparently thus primarily affected, are ibund in fact 
to be affected secondarily, it often happens that the secondary or 
sympathetic disorder is sometimes the most important, sometimes 
most prominent, and sometimes both in conjunction. 

7. That the sympathy between all parts is mutual, without ex- 
ception, so that the influence travels either way ; but that con- 
siderable differences are observed in the phenomena in different 
organs. 

8. The sympathy may be equal, as well as mutual, being as 
readily excited by the affection of either one of any two or more 
organs. 

9. That, on the contrary, though mutual, it may be much more 
readily excited in any two organs, accordingly as one or other may 
be primarily affected. 

10. That, in discovering the sympathy of any one organ, with 
any other more obviously deranged, pain, or indeed sensation, 
of any kind, is by no means a necessary, nor indeed a frequently, 
existing condition. 

1 1 . That the manner in which an organ is executing its functions 
should be the constant, as it is the most important, object of enquiry. 

12. That this enquiry frequently unfolds the reason why the 
system has been preserved apparently free from disorder, whilst 
some important function may have been obviously imperfectly 
performed. 

13. That, in the management of disease, the ordinary mode of 
addressing our treatment to the organ which we believe to have 
been primarily affected, is to be regarded as a good general rule, 
but still as one which admits of many important exceptions. 

14. That, as sympathetic disordering influences may travel 
either way between any two organs, so may influences of a 
salutary tendency. 

15. That the exceptions, therefore, to the general rule 13 (by 
which the sympathetic disorder of organs is addressed through the 
organs primarily affected) takes place — First : Where all our reme- 
dies have failed. Secondly : Where, from any peculiar condition 
of the primarily affected organ, or from some idiosyncrasy in the 
individual, the remedies on which experience has placed most reli- 
ance may be inj urious. Thirdly : Where, though the remedy may be 
successfiil as regards the present ailment, we have good ground for 



219 



perceiving that it may be ultimately of injurious consequence or 
tendency. Fourthly : In cases where remedies prove injurious by 
acting on some organ to which they are not directed. 

16. In all these cases, the best effects may be obtained by di- 
recting our attention to organs secondarily affected; by which 
remedies, wliich were inert or injurious before, may be rendered 
active and beneficial : or, where they cannot be so rendered, they 
may be dispensed with altogether. 

17. That a very important extension of this plan of acting 
(under proper restrictions) on organs secondarily affected, consists 
in the fact, that the same good results may be sometimes obtained 
by acting on organs which are neither primarily nor secondarily 
affected ; organs, indeed, which manifest no disorder at all, pro- 
vided only that they are organs which have a known sympathy 
with those which are affected — and this whether the affection be 
primary or secondary. 

Lastly. That these facts not only enlarge our views of treating 
diseases of the body, with reference to the machine as a whole, but 
that they are calculated to give our efforts a safe and scientific di- 
rection, and one in exact conformity with that which Nature herself 
observes daily in the preservation of health, and very commonly 
in the most marked manner in the removal of disease. 



220 



DISCOURSE VI. 

OF INFLAMMATION. 



As I am now about to commence the consideration of diseases, 
I will offer a few remarks on a passage in Mr. Hunter's writings, 
wliich I must think (with all my admiration of him) calculated to 
convey an erroneous impression. 

Mr. Hunter, in his Remarks on Adhesion, or Union b}' the 
first Intention, speaks of injuries and disease as if there were dis- 
tinctions between them of a kind which, on examination, will not, 
I think, be found tenable ; and the passage seems to me to tend 
rather to obscure the law, of which, at the same time, like many 
other reflections of this wonderful man, it points to the discovery. 

" I may observe," says he, " that all alterations in the body 
are the result of injury or disease ; and that all deviations from its 
natural actions arise from a new disposition (?) being formed. In- 
jury is commonly simple ; disease more complicated. The dispo- 
sitions arising from these are of three Idnds : The first is the 
disposition of restoration, in consequence of some immediate mis- 
chief, and is the most simple (?) The second is the disposition 
arising from necessity, as, for mstance, that which produces thick- 
ening of parts, ulceration, &c. This is a little more complicated 
than the former, as it may arise both from accident and disease, 
and therefore becomes a compound of the two. The third is a 
disposition in consequence of disease, which is more complicated 
than either, as diseases are infinite. Yet many diseases, although 
complex in their natures, are so simple in their extent, as to allow 
the removal of the diseased part, becoming, when that is done, 
similar to many accidents. As disease is a wTong action of the 
living parts, the restoration to health must first consist in stopping 
the diseased dispositions and actions, and then in a retrograde mo- 
tion towards health." 

Now, notwithstanding the somewhat hasty generalization in the 
above (as 1 consider it) difficult passage, there is abundant evi- 



221 



dence that it arises from beautifully enlarged views, which we can 
only appreciate by reflecting duly on the state of medical science 
at the time it was written. Yet, as I would earnestly entreat 
every one, and especially those who have made some progress in ele- 
mentary matters, to study most profoundly this Argus-eyed author, 
as Mr. Abernethy used to call him, so would I guard them, if I 
could, from receiving any of the few erroneous notions which may 
be here and there mixed up with the treasure of truth presented to 
them. I would therefore humbly, yet firmly, urge, that there is in 
Nature no such distinction between injury and disease as that im- 
plied in the passage which I have quoted. 

An injury, in the common sense of the word, mechanically de- 
ranges a part of the body, and immediately (in conformity with a 
law in the animal economy) repair commences, which is demon- 
strated by certain phenomena. If the economy be sound, the exe- 
cution of the law is vigorous and efficient, the repair complete ; 
if the economy be disordered, the law is carried out with difficulty. 
In the former case, the wound heals ; or, if the inju.rious influence 
be not of a mechanical kind, it is mitigated by some action which, 
repels it, or relieves the system from it by secretion ; examples of 
which are occasionally seen in transient affections of the skin or 
bowels. But, if the law^ be carried out imperfectly, then, instead 
of the healing of the wound in a direct and uninterrupted manner, 
we have suppuration, abscess, erysipelas, or mortification, or it 
may not heal, and the death of the patient may ensue*. So, when 
the system is affected by injurious influences of other kinds, w^hich 
are perfectly repelled, — as cold, for example, — we have a light, tran- 
sient, speedy, and salutary excitement, evidenced by increase of 
secretion, — from the skin, perhaps, or bowels, or kidney, — or by 



* Here is, in Mr. Hunter, a clear recognition of this distinction as regards 
local phenomena. " In injuries, arising from accident, we have hitherto supposed 
that the parts have no tendency to any diseased action, independently of the acci- 
dent ; for, if they have, it is probable that such a tendency may be stronger than 
the disposition for restoration ; and, in that case, they will fall into the peculiar dis- 
eased action, &c. Let us take cancer and scrofula as examples, and we shall find 
that, if a part be hurt which has a strong tendency to scrofula, it will most pro- 
bably run into a scrofulous mode of action, in preference to that of restoration, &c. ; 
or if a woman, beyond thirty years of age, receive a blow in the breast, it is more 
likely to acquire the cancerous mode of action than that of restoration, which 
should be well distinguished from what is immediately consequent on the inflam- 
mation ; for on this depends a knowledge of diseases." The error here, is the 
reference being wholly to the fart. 



222 

one organ undertaking the office of another, to which injurious in- 
fluences may have been applied (see Sympathy) ; but, if the system 
be incapable of carrj-ing out the preservative law thus salutarily, 
w^e have excitement, debility, fever, and those various suspensions 
or embarrassments of function which we call disease. This ren- 
ders it necessary that, if we say any thing about the differences of 
injury and disease, the matter should be differently stated ; and it 
appears to me that the truth and simplicity of another view of it 
are alike apparent. 

Now^, a wound is an injury to the body. Granted. The pro- 
cesses which it induces, as distinguishable from ordinary habits of 
the economy, are new actions ; but they are not new dispositions. 
Whatever takes place in the part, is an effort of Nature to repair 
the injury : in this case, mechanical. Disease is no more than 
this. Some injurious influence has acted on the body ; no matter 
whether air, food, subtile forms of matter, poisons, or what else : 
this is the cause of the disease. The body institutes efforts to ex- 
pel the injurious influence or to repair its consequences. These 
efforts, as in regard to the wound, may be successful or abortive ; 
but, in either case, they are the symptoms, as we call them, of dis- 
ease, and by them we judge of the strength of the reparative ten- 
denc}-. So far as we can see, in all cases where the influence is 
not necessarily destructive per se, the success or failure of the 
effort in both cases, that is, of injury or disease, depends on the 
same general cause, namely, the condition of the body at the time 
it became injured. 

The only difference between these two cases is, that, in the 
wound, the nature of the injury is apparent and demonstrable ; 
w^hilst, in the disease, it is often very obscure, or altogether hidden 
from us. 

In the wound, we know what those processes are which predi- 
cate success, and those which augur delay, risk, or failure ; but, in 
disease, our ignorance frequently, and indeed generally, prevents lis 
from discriminating between those processes which should be en- 
couraged as indications of a preservative power or tendency, or 
which require, as such, adjustment in then' degree; and those 
wliich should be repressed or subdued as presaging failure. Thus, 
if a w^ound fester, or suppurate, or become erysipelatous, or slough, 
I know pretty accurately the kind and extent of the departure 
from the preser^-ative law of the animal economy, as presented in 
the successful repair of this kind of injury. But, if I have a pa- 



223 



tieiit with vomiting, diarrhoea, with or without morbid biliary secre- 
tions, or what not, I know not how much of it may be due to preserv- 
ative power, and how much to the absence of this power. In this 
distinction consists the true knowledge of the nature and treatment 
of disease. Again, Mr. Hunter observes, " that injuries have, in all 
cases, a tendency to produce both the disposition and the means 
of cure, which is a circumstance not belonging to disease," &c. 
But this is certainly erroneous. There is no exemplification of any 
disease or disorder of the body, not shewing a tendency " both to 
disposition and means of cure," which does not apply with at least 
as much force to many, too many indeed, cases of mechanical in- 
jury. A scratch in the skin leads, in certain cases, to death, as 
certaiuly as a poison in the stomach does. The essential difference, 
in regard to injuries and diseases, is simply this, — that we have con- 
siderable information in regard to the one, and comparatively little 
knowledge in regard to the other. 

In endeavouring to teach any subject embracing a multiplicity 
and variety of phenomena, there are usually several modes of pro- 
ceeding, each having certain advantages, and certain objections. 
In making a selection, it will perhaps be generally best for a man 
to adopt that arrangement in which the several objects present 
themselves, in the easiest succession, to his own perceptions ; since, 
whether this prove the best plan or not, in an absolute sense, it 
will probably prove so in regard to his powers of managing the 
subject. The subject of inflammation is so extensive, that it is 
impossible to say all that might be said upon it, in any work ap- 
proximating to an elementary character : but it is very possible to 
say enough to give you sound and clear views of its essential cha- 
racteristics, and to unfold principles on which you may found 
further enquiries. Now, the first thing is, to define the general 
nature of the subject of which we propose to treat, and the no- 
menclature in connection with it. Secondly, to describe the facts 
or phenomena in relation to it ; and, lastly, to explain the law to 
which such facts are to be referred. If this be done, the w^iole has 
all the properties (both in regard to the manner in which it is 
taught, and the ultimate object of the lesson) of science. So far 
as I know, this has never been hitherto done in regard to inflam- 
mation. Much less has it been followed up by what to us is the 
essential thing, — namely, by shewing how the treatment should 
arise out of the nature of the malady. The plan is, then, — first, a 
general definition of inflammation, and its nomenclature ; secondly, 



224 



a description of the phenomena which it exhibits ; thirdly, the law 
to which these phenomena are to be referred ; and, lastly, the 
treatment which necessarily arises out of it. 

The term Inflammation, in its primary and simple acceptation, 
merely means the co-existence of four things in any part of the 
body; — these are, increased heat, redness, pain, and swelling; to 
which throbbing is generally added. This definition is borrowed 
from one of its most remarkable forms, occurring in situations 
where w^e have the power of seeing it ; and were inflammation 
really confined to the phenomena involved in the foregoing defini- 
tion, the discussion of the subject would be much narrowed. 

In pursuing the subject, however, we find that we are obliged to 
employ the term Inflammation (with some modifying epithet, per- 
haps) in a much more enlarged sense. We find it influenced by its 
degree, by the part, and by several other circumstances, so that it 
becomes presented to us under forms so various, as to render the 
simple definition, with which w^e started, not only not sufficiently 
comprehensive, but, on many occasions, wholly inapplicable : and, 
as we pursue the subject still farther, we find inflammation, under 
some modification or other, operating so universally in diseases, that 
at last we perceive that it is more or less connected with almost 
ever}' malady presented to the surgeon. Now I admit, that the first 
announcement of this fact has a discouraging aspect ; but, like all 
other truths, when properly understood, it has quite a contrary 
character. If I mistake not, the number and apparent dissimi- 
larity of the phenomena are the very circumstances which impel 
us to that mode of investigation wliich can alone enable us to de- 
termine the law of their occurrence. 

I wish to impress this on you, because it will prepare you for 
what little difficulty there is ; it will tend to fix your attention ; it 
will put you early in the possession of facts, without which w^e 
cannot progress ; and thus alike prevent unnecessary retrogressions 
on your part, and unprnfitaMe repetitions on mine. We shall sup- 
pose, then, that a part is affected by heat, redness, pain, sw^elling, 
and throbbing, —and now, what is to come next ? 

RESOLUTION. 

All these circumstances or symptoms, we will say, gradually sub- 
side, and the inflammation is said to end in Resolution: the part 
being restored to its natural condition : or 



225 



ADHEj^ION. 

If the inflammation have taken place in a womid, there is a sub- 
stance thrown out on it which we call coagulating lymph ; v^es- 
sels shoot from the opposing surfaces, and the wound unites : or 

SUPPURATION. 

The inflammation becoming greater ; that is, either occup}dng a 
greater district, or having its characters more strongly developed, 
or both ; is attended by the formation of matter (abscess) ; and 
then those portions of the cavity of this abscess which do not im- 
mediately adhere on being emptied of the matter, are healed by a 
new structure, deposited in the form of little, red, fleshy -looking 
specks (granulations), on a raw surface thus left : or 

ULCERATION. 

This surface does not heal, but a sore remains, more or less red ; 
perhaps discharging matter : or 

MORTIFICATION. 

Sometimes the skin, and the parts immediately beneath it, are re- 
jected altogether from the system, having undergone a previous 
change, as if they had been rotten, and wholly unlike their original 
appearance. 

These are regarded as the terminations of inflammation, since 
all others are easily referrible to modifications of one or other of 
them. Some parts become thickened ; but this is only a greater 
efiiision of that coagulating lymph which produces adhesion, and 
so on. If inflammation be active, circumscribed, and run quickly 
into suppuration, we call it phlegmonous ; if it be diffused, and 
the suppuration be mixed with other things, hereafter to be de- 
scribed, we call it erysipelas. Then we have other names, which 
we apply to certain inflammatory appearances ; but those men- 
tioned will be suflicient for our present purpose. We will now, 
then, consider inflammation under its most simple form, and then 
proceed to some of its more striking examples. 

As our object is to observe Nature in an unembarrassed ex- 

Q 



226 



ercise of her powers, we must take a case as little disturbed bj 
disease as possible ; and, in civilized communities, this is not very 
easy in the human subject. Indeed, it can only be done with rea- 
sonable confidence when we select a healthy subject : a wound, 
which is not, by its extent or severity, calculated to disturb the 
animal oeconomy ; or which has been inflicted intentionally, as in 
an operation, with a previous endeavour to put the health in a quiet 
condition. For obvious reasons, also, when the choice is open to 
us, and all other things are alike, w^e should let our case be one in 
which the operation has been undertaken for the removal of some 
disfigurement, rather than for the extirpation of disease. For carry- 
ing out these objects, a wound by a sharp-cutting instrument, as 
doing the least violence, should be preferred. Now, then, to observe 
the obvious phenomena. In the first place, there is bleeding and 
pain ; then the bleeding gradually ceases, and the pain becomes miti- 
gated. We will now suppose that we have brought the edges of 
the wound into contact, with the exception of a few points, at 
which there is a small interval still remaining. The wound now 
feels pretty comfortable ; there is little or no pain: but there comes 
on a feeling of increased heat, there is some sense of throbbing in 
the part ; and, if the wound, or the skin in its immediate vicinity, 
be touched, there is some alteration in sensation ; that is, the part 
is rather tender ; and, if it be the finger, there is some impairment 
of the sense of tou(;h. Thus, a body is more apt to impart to it a 
general notion of hardness, softness, or what not, than a perfectly 
accurate and well-defined perception of its physical or mechanical 
properties. Moreover, the part is also a little red and swollen. 

Now, if we continue our examination, we find that, at the end, 
we will say of about twenty -four hours, those parts of the wound 
which were in perfect contact, are united ; and we recognize the 
line of union exhibiting, perhaps, the smallest possible appearance 
of moisture. The spaces where sides of the wound were not 
brought close together, afford much of the same appearance as 
yesterday, except a little dryness from evaporation. On the adja- 
cent edge, however, we see a faint redness ; and soon there appears 
a thin, semi-transparent sort of secretion, which, about the third 
day, assumes the following characters. It is yellowish-white, 
cream-like, somewhat unctuous to the touch, usually inodorous, or 
somewhat mawkish in smell, though sometimes fetid. This is 
what we call matter or pus, and the production of it is suppura- 
tion. This secretion increases ; but, in the case before us, amounts 



227 



to scarcely a greater quantity than is sufficient for a liberal dress- 
ing to the part it covers. Any coagulated blood, or dried matter, 
is generally loosened, and the discharge now begins rather to di- 
minish. The cut surface becomes level and smooth, and represents 
a congeries of little red, pointed, fleshy -looking bodies, which, first 
peeping up through the matter, now occupy the surface. We ob- 
serve also, around the edge, a grey slate-coloured line, which we 
find to be a delicate pellicle of that which is to be the new skin. 
The wound now heals ; and, as }'ou observe, from the circumfer- 
ence to the centre ; and the part is, in a few days, restored. As 
it heals, the wound becomes more and more contracted, and the 
contraction continues even after the healing is completed : the 
effect of which is, that when all the processes have ceased, the 
space represented by the scar is so much less than that occupied 
by the wound, that no person, without previous information on the 
subject, would form any idea of a wound by the measure of the 
scar or cicatrix. Now these are but sketchy shado wings, as it 
were, of the important process which we are considering; but, 
nevertheless, they are truly phenomena of inflammation. We 
have had heat, redness, pain, swelling, and throbbing — very slight, 
I grant you, — no disturbance : in fact, we have nothing to say but 
that the wound healed. Now we will go back, and suppose the 
same wound in another person ; which proceeds in the following 
manner. 

In the first place, we find that the parts brought together do 
not unite as in the other case ; that the swelling, heat, pain, and 
throbbing, are greater ; that the tenderness is considerable. The 
wound festers, as it is said. We put on a poultice ; we direct the 
part to be kept quiet. The general swelling seems greater in a 
particular spot ; we feel that it is elastic. We say that there is 
matter there, and, either allowing it to find its own way, or lettuig 
it out by a lancet, the pain, throbbing, &c. subside ; the little ca- 
vity occupied by the matter collapses, and its sides unite by ad- 
hesion ; or, perhaps, some portion of it unites by granulation, in 
the way I mentioned in the former case, in regard to those parts 
which had not been brought into contact. We here observe that 
the part is repaired as before ; but its reparation has occupied more 
time, and has been accompanied by more suffering ; there has been 
more matter ; its secretion has been attended by different circum- 
stances (there was no confinement of it, or abscess, in the former 

Q 2 



228 



case) ; and we remarked also, that the patient seemed even a little 
disturbed, generally, by the pain, &c. of the whole proceeding. 

Before I put a third case, it may be as well to speak of matter, 
or pus. As I have said, it is a whitish-yellow, cream-coloured 
fluid, unctuous to the feel, and emitting little odour : examined by 
a microscope, it appears to be composed of globules, swimming in 
a fluid, coagulable by muriate of ammonia. 

The time required for the secretion of this pus is uncertain ; 
sometimes it is secreted at once, as pus ; but, more commonly, it 
is preceded by the secretion of some other fluid, which differs from 
pus so far that it does not contain the same number of globules ; 
these are more transparent, and the fluid in which they swim is 
not coagulable by muriate of ammonia. This last circumstance 
seems peculiar to pus ; but the point has not been satisfactorily ex- 
amined. Several cruel experiments have been made on this sub- 
ject. But the best, I think, involved no cruelty at all ; whilst it had 
the advantage of being made on the human subject. This was one 
of those made by Sir Everard Home ; and consisted in watching and 
examining, first the serum, and subsequently the other products 
of the inflammation excited by a blister on a young man's chest. 

The chemical composition of pus has not, I think, been accu- 
rately determined ; nor does this mode of enquiry seem very pro- 
mising in regard to any information which it is likely to give us as 
to the laws of its formation. Mr. Hunter made some experiments 
by dissolving pus and several other forms of animal matter, such 
as tendon, muscle, and white of egg, in acid, and then precipitat- 
ing the solution with alkali ; but the examination of the precipi- 
tates shewed nothing particularly different in either case : all 
yielded a sort of flaky substance. He also reversed the experi- 
ment, dissolving the animal matters in the caustic alkali, and pre- 
cipitating the solution by muriatic acid ; but the precipitates, exa- 
mined by a magnifier, shewed no perceptible difference in charac- 
ter. Albumen, fatty matter, various salts, &c. are found as consti- 
tuent elements in pus ; and it seems that the fluid coagulable by 
muriate of ammonia, is more abundant in healthy pus than in 
some other of its numerous varieties ; but little is known of any 
value on this subject, and therefore I shall not enlarge on it. The 
uses of pus will be adverted to when I consider the law under 
which inflammation seems to occur. The distinction between pus 
and mucus have also been made the subject of much consideration. 



229 



Pus is specifically heavier than water, in which it therefore sinks ; 
whilst mucus, being lighter, floats, and so on : but neither this, nor 
anj other distinction between these fluids, is important, because 
the surfaces which can secrete mucus, can also secrete pus. The 
irritation or disordered action giving rise to the secretion, is always 
the thing to be considered ; and this we judge of very imperfectly, 
by the mere examination of the product. 

This investigation is usually regarded with interest in affec- 
tions of the lungs ; but, if the mucous membrane of the respiratory 
organs can secrete pus, of which there can be no doubt, it is obvious 
that any attempt to determine the seat of the disease, whether in the 
substance of the lungs, or in the lining of the ramifications of the 
windpipe, by the characters of pus and mucus, must be unavailing*. 

We regard pus, possessing the above pecuharities, as good or 
healthy, because they are such as characterize this secretion when 
produced by actions that are healthy or reparative. Nevertheless, 
you may have good pus, as far as its physical appearances are con- 
cerned, without actions which are obviously reparative. Pus is 
secreted in abscesses, from ulcers, from torn surfaces, and also 
without previous injury, and, under certain circumstances, from 
every surface in the body. It is true, that in the skin there are 
always accompanjdug processes, which involve, at one period or 
other, lesion of the surface. But secretions also take place under 
circumstances somewhat similar to those under which " good pus" 
is secreted ; which, not answering the description I have given, 
induce us to admit the term puriform : and, in this sense, pus 
exhibits a great variety of characters, most of them beiug very 
different from those which it usually presents. Foe tor is one of 
them. The matter may exhale a most offensive odour, and this of 
great variety ; nor is the presence of offensive odour necessarily 
prohibitory of the progi'ess of reparative processes. 

I think the most insupportable odour I ever recollect to have 
met with, was from an apparently healthy granulating surface, sub- 
sequent to a severe laceration. Occasionally, particular forms of 
disease evince characteristic odours in their secretions. This is 
usually the case in inflammation attending cancer, in certain de- 
structive sores (technically termed sloughing phagedena), and 

* We are indebted to Mr. Hunter for shewing that pus is a secretion not ne- 
cessarily implying any destruction of parts ; the idea, previous to his time, being, 
on the contrary, that pus, somehow or other, resulted from a conversion of solid 
parts into that fluid. 



230 



perhaps iu sores the result of the abuse of mercury. But we must 
be careful in regard to this point : the odour does not seem a very 
essential circumstance ; for I have known many scrofulous sores 
exhale an exceedingly offensive and peculiar smell ; yet I have 
witnessed the very same smell arising from sores where there was 
no reason of any kind to suspect the existence of scrofula ; and 
so, indeed, though less frequently, of the other diseases of which I 
have spoken. — Consistence. Then, again, the secretions from sur- 
faces under inflammation are very different in their consistence. 
Sometimes, with the general characters of pus, they are unusually 
thick ; at others, they are streaked with blood ; at others, again, 
we see fiocculi floating in them like broken-down cellular tissue ; 
and, occasionally, we observe shreds of cellular tissue mixed with 
them. Sometimes we find matter of this kind to be much thinner 
than good pus ; and, in some cases, quite thin and transparent. I 
once opened an abscess, and let out a quantity of ordinary yellow 
pus ; the abscess filled again, and being again emptied, the fluid was 
straws-coloured, and perfectly clear, like pale sherry : this, however, 
in abscesses, I apprehend to be rare ; but aqueous secretions are 
common enough under a variety of other circumstances, especially 
in unhealthy ulcers. Ordinary pus seldom irritates the surface 
which secretes it, or that in its vicinity, unless it be suffered to 
accumulate ; but w^heii the secretion is thin, it is often highly irri- 
tating, and even excoriating to the surrounding parts. Occasion- 
ally, also, the secretions from diseased surfaces are discoloured, being 
more or less bloody and thin at the same time. Thus we speak of a 
bloody sanies and thin ichor, as descriptive of these aqueous or dis- 
coloured products. A number of other appearances, intermediate 
between those which I have mentioned, are also observed ; but, for 
purposes of description, they may usually be ranged under one or 
other of the foregoing varieties. The only point on which they 
agree is (what on aU subjects it is most important to remember, as 
generally pointing, in some way or other, to their true relations to 
the laws of animal oeconomy), that they are all alike new products, 
such as we never find in a natural state of the body. Therefore 
it is clear that they are superpositions, and of course that some 
purpose is answered by them. What this purpose may be, must 
be considered as we proceed. 

I shall now, then, revert to our original wound ; and suppose 
that, in a third person, it is followed by results again different 
from those which I have hitherto supposed. The wound, then, as 



231 



iu the second case, does not unite ; the redness beginnmg m a 
small district, extends, — nay, it creeps, as it were, — up the limb, 
until it occupies the whole of it : there is great pain, heat, throb- 
bing; the member becomes enormously swollen; the patient is 
exceedingly disturbed ; he is thirsty, his tongue foul and dry, his 
pulse much accelerated ; perhaps he may have pain in the head, 
even proceeding to delirium. Little blisters form on certain parts ; 
these are followed by a darkening of the surface, which breaks, as 
it were, discharging a strange mixture of pus, more or less per- 
fectly developed, mixed with blood and shreddy cellular tissue. A 
large portion of skin, having undergone a curious alteration, is 
mortified, as we term it, and is thrown off from the surrounding 
parts ; the absorbent vessels isolating it from them by removing 
the connecting surface. Now, or perhaps a little time previous, 
certain measures are adopted, and the patient slowly recovers ; or, 
in other cases, disturbance of the head continuing, there is mutter- 
ing delirium; and though a great excitement and frequency of 
pulse may continue, still the patient's tongue becomes very dark, 
and even black. The pulse loses all evidence of excitement, ex- 
cept its frequency, and the patient sinks, and is said to have 
died of inflammation, which we call erysipelas, or phlegmonoid 
erysipelas. 

In the four preceding cases (w^hich, though here put hypotheti- 
cally, are, you must understand, of frequent occurrence in practice, 
as I shall by and by exemplify), we observe very different se- 
quences following a clean cut with a sharp instrument. And had 1 
begun by supposing that the injury were a slight scratch, or, indeed, 
inflicted in any other manner, I should have had to tell you the 
same story in all essential points ; that is, I should have had to 
relate successful repair of the injury, a repair more slowly ac- 
complished, and a case in w^hich no repair took place. Now, at 
first sight, we might be disposed to regard these various sequences 
as the necessary result of local injury ; but you must not do this ; 
all I wishyou to do at present, is, to note facts, which cannot be mis- 
taken ; namely, that the circumstances in question followed certain 
local injuries, in the severity of the local characters of which we 
could distinguish no difference. We shall immediately get into 
difiiculty by regarding them as effects 7iec€ssarily resulting from the 
wound in either case ; because we find that they sometimes occur 
without any w^ound or local injury at all. 

In supposing the w^ound in the integuments of the body, and 



232 



in stating tliat tlie various results which followed it in different 
cases, occurred in others without any wound at all, I should ob- 
serve that there are a multitude of inflammations of the skin, very 
different in appearance from any of these ; and that the whole ca- 
talogue of diseases of the skin are but modifications of inflam- 
matory actions, resulting from causes to which I shall advert as I 
proceed, but which are altogether independent of local violence or 
injury. Here I only make the remark as preliminary to the state- 
ment of the terminations to which inflammatory actions of the 
skin seem to be disposed. It must be remembered, that inflam- 
mation in any part may be accompanied by adhesion, suppuration, 
efiusion, thickening, ulceration, or mortification ; and that when 
we talk of the disposition of parts to this or that process, we speak, 
generally, as supposing the inflammation to have considerable range 
of degree, short of extensive violence, and all other things being 
alike. In this view of the matter, then, we must regard the ten- 
dency of inflammation of the skin to suppuration, as its leading 
character ; but scarcely, I think, in so striking a manner as the 
dispositions of other parts are presented to us. We should be 
nearer the mark if we were to say, effusion ; and to regard sup- 
puration (as indeed, but for conventional objections, we ought to 
do) as one example of it. The truth is, that no surface of the 
body presents examples of inflammation in such endless variety of 
form or severity, as the skin ; so that, amidst such a number and 
complexity of actions, we cannot adjust their tendency with the 
same ease as in other parts. The skin is not only thus the seat of 
innumerable actions in itself, but it becomes more frequently in- 
volved in actions which do not commence in it, than any other 
organ. Of these, abscesses, boils, carbuncles, &c. are examples. 
Of the two latter I shall speak, as distinct subjects, in the present 
vohime. 

I would say a few words, by way of definition, of a common 
abscess. A change of sensation takes place in some part of the 
body, varying from slight uneasiness to acute suffering. The part 
feels tender, and is observed to swell. This swelling increases ; 
the skin becomes more or less red ; the swelling feels somewhat 
elastic in its central part, but hard and firm at its circumference. 
The redness of the skin, the pain and tenderness increasing, sen- 
sations of throbbing are felt in the part; the swelling is now 
observed to be more or less of a conical form (the abscess is said 
to point) ; and the skin, at or near the apex of the cone, is observed 



233 



to become thiuuer ; the elasticity, already felt, has gradually been 
developing a sensation, which is now clearly that resulting from the 
fluctuation of a fluid. If nothing be now done by art, Nature 
continues to thin the skin at or near the point of the cone, which, 
being at length entirely removed at that point, nothing but the cu- 
ticle or scarf-skin remains ; and, this bursting, the matter is dis- 
charged. The patient, who all along had experienced nothing but 
increasing pain, is all at once easy. The abscess discharges its 
contents ; its sides coalesce, all but a small wound, the natural en- 
largement of the original aperture through which the matter has 
escaped ; and this is healed by granulation, and the subsequent 
superposition of new skin, as I have before mentioned. The dis- 
charge from the abscess we suppose to be healthy pus, as it is 
called ; but it may present any of its multiform varieties. In such a 
case, the abscess is said to be a common abscess ; the inflammation, 
common inflammation. The thinning of the skin is evidently cal- 
culated to bring the matter to the surface ; and the hardness of 
which I spoke as characterizing the circumference, is found to be 
the result of adhesion of the skin to the subjacent parts, calculated, 
as we think, to limit the extent of the inflammation ; because, when 
we find it absent, the inflammation has no natural line of demar- 
cation, but spreads in any and every extent and direction, — of which 
erysipelas is an example. You see, then, that the inflammation, 
which produced suppuration in the central part of the abscess, pro- 
duced adhesion only at the circumference, as was remarked by 
John Hunter. 

Now, as I shall have a great deal to say, some time hence, on 
abscesses, I shall merely observe, at present, that you may have 
abscesses with various degrees of what we call the signs of in- 
flammation (heat, swelling, pain, redness, and throbbing), or you 
may have them of any magnitude without any of these phenomena 
being perceptible. As these abscesses are in general a long time 
in forming, and a long time in being got rid of, and as they may 
exist for a long time without augmenting any apparent disorder, 
w^e say they are chronic abscesses. Of many, we are able to see 
the use ; as when an abscess forms over foreign bodies, as over 
dead bone, and heals immediately on the expulsion of the oflending 
body. But, of the causes of others, we are often very ignorant ; 
although I hope to be able to throw some light on the subject as 
we proceed. 

Let us now further consider inflammation as modified by its 
seat, or by the structure in which it occurs. 



234 



MUCOUS MEMBRANES. 

The surface next in continuation with the skin is the lining of 
the various canals of the body ; which linings form what we term 
the mucous membranes. That covering the throat enables us to - 
see what happens in inflammation ; and further enquiry shews it to 
afford a very good type of the results by which the disposition of 
these structures, when inflamed, is characterized. A man has a 
sore throat, as it is called : he feels his throat stiff ; swallowing is 
painful ; the membrane seems to have its extensile property im- 
paired ; it is tender also. If we look at the throat, we shall see 
differences according to the degree of inflammation. The throat 
may appear red throughout ; and this, with a slight spot or two of 
increased secretion, more or less like pus or mucus, may be all that 
we can see ; or we may perceive, in addition, a large quantity of 
yellow secretion, or an ulcer, or many ulcers, secreting pus ;— nay, 
we may see a surface of slough or mortification ; — but, if we ex- 
amine a thousand cases, w^e shall never see any other than some 
variety of degree or combination of the circumstances which I 
have mentioned. In almost all, except those of very trivial degree 
indeed, we shall see the secretion of pus, or such an increase and 
alteration of the mucous secretion of the part as are not distin- 
guishable from pus ; and, if the inflammation be only moderate in 
degree, we shall usually observe more or less ulceration with this 
increased secretion. Now, whether we examine the lining of the 
wind-pipe and its ramifications, that of the stomach and intestines, 
the bladder, urethra, and vagina, or that covering the white of the 
eye, all of which may be regarded as mucous membranes, we shall 
observe little essential difference in the actions to which their dis- 
positions tend, when the respective parts are affected by inflam- 
mation. That is to say, that mucous membranes shew a ready 
disposition to increase their usual secretions, or to secrete matter, 
and to take on the process of ulceration ; but that they evince very 
little disposition to adhere together. 

You must not suppose the appearances of all mucous mem- 
branes under inflammation are identical, or that you would not see 
differences between a piece of that lining an intestine, and of that 
lining the wind-pipe. Nevertheless, their modifications, in appear- 
ance, are not essential differences ; and they depend more on natural 
diversities of appearance than on particulars superadded by inflam- 
mation. Neither are you to imagine that the fact .of various struc- 



235 



tures e\diicing an incliuatiou to this or that mode of action, when 
inflamed, is at all inconsistent with their ability to assume any other 
under peculiar circumstances. Thus, if we take a mucous mem- 
brane, we find it lining a cavity, which it is of the utmost impor- 
tance should be kept open, and which a tendency to adhesive ac- 
tion would, of course, tend to close ; so, if we take the serous* 
membranes, of which I shall speak in the next place, we find them 
also lining cavities, as it w^ere — the abdomen or chest, for example, 
— but with this essential difference, that the object here is, on the 
contrary, to keep the cavity closed. So we find their tendencies 
in disease in beautiful harmony with their functions in health : the 
mucous linings of canals presenting very little disposition to adhe- 
sion ; whilst, in the cavities lined by serous membranes, the least 
opening has always a tendency to effect its own closure by the ad- 
hesive inflammation which is excited. 

Yet, under violent actions, these peculiarities, like many others 
we know of, may be interfered with, and the power of evincing 
them annulled ; so that, in certain cases, we see the contrary of 
all this. That is, we see the sides of canals united more or less 
closely by bands of coagulable lymph thrown across the tube ; and, 
on the other hand, we see the serous membrane departing from its 
ordinary habit, and secreting large quantities of matter, as in the 
chest, constituting what we call empyemat- These, however, are 
exceptions which only serve to mark the rule, and to improve our 
knowledge, as we shall see, of the resources of the animal oeconomy-, 
I would observe, that mucous membranes, notwithstanding their 
readiness to secrete pus, when inflamed, generally commence by 
increasing their usual secretion, with some little alteration, perhaps, 
of quality, and that the assumption of the puriform character is 
gradual. This is useful as helping us, amongst other things, to ad- 
just the real value which is to be attached to those rules, or endea- 
vours at rules, by w^hich we are told pus is to be distinguished from 
mucus. 

Now, I have spoken most particularly about mucous and serous 
membranes ; because, whatever you know in relation to these parts 
and the skin, to which I have also directed your attention, relates 



* Those which line cavities and give investments to the organs which those 
cavities contain, as in the skull, chest, abdomen, &c. and their respective \iscera. 

+ This was one of the demonstrations used by Mr. Hunter to shew that pus 
might be secreted, the surface secreting it remaining unbroken. 



236 



not only to the most frequent seats of inflammation, but also to 
the most important exemplifications of it which occur in practice. 
It involves, in fact, inflammation of the membranes of the brain, 
heart, and lungs ; of the viscera, of the abdomen, and pelvis, be- 
sides the linings of the various viscera ; and, at least, one very 
important class of diseases of the eye. In regard to other struc- 
tures, as influencing the course of inflammation, I need say nothing 
farther than that all parts highly organized, — that is, with large 
supplies of blood-vessels and nerves, — seem most inclined to ad- 
hesion to the surrounding parts, and to suppuration ; whilst parts 
with but small blood-vessels and nerves, like bone, ligament, and 
gristle, seem very readily to run into ulceration and mortification ; 
and, although they severally exhibit respective peculiarities, yet 
this is, in a general sense, true of them all. 

There is one part of the body which is peculiar — I mean the 
gums ; that is, they are very vascular, and, when healthy, very in- 
sensitive. Their vascularity seems to prevent them from becoming 
often inflamed, since they bleed so readily ; but suppuration seems 
their leading disposition when inflammation really does take place : 
though occasionally they exhibit unusual powers of adding to their 
natural structure (hypertrophy). 

FURTHER REMARKS ON SEROUS MEMBRANES. 

In examining inflammation, then, as it occurs in Nature, we 
will proceed to other exemplifications of it. A person is wounded 
in the abdomen, and recovers. In this case, an opening is made 
into a cavity presenting a large surface. Inflammation is set up 
around the aperture ; the intestine, corresponding to that part, is 
surrounded by a circle of coagulating lymph, which, becoming 
organized, glues the parts together, and thus shuts out, as it were, 
the district of the wound from the general cavity. The healing of 
the external wound is not different from any other : such parts as 
are brought into contact unite at once ; those w^hich are more or 
less separated, at first secrete matter ; then granulations grow up, 
and, gradually filling up the part, become covered with skin, as I 
have already mentioned. 

In another case, we observe very different results. On the in- 
fliction of the wound, and the consequent exposure of a portion of 
intestine, the patient is faint ; he feels cold ; his pulse is low : all 
this may have happened in the former case. His condition, how- 



237 



ever, changes ; pain arises perhaps in the district of the wound ; 
and this gradually, but rapidly, extends over the whole abdomen. 
The whole surface is exquisitely tender ; his pulse becomes rapid, 
though, perhaps, small in volume. His stomach rejects every 
thing ; his bowels do not act ; he has the excitement of fever ; he 
sinks, and dies. We examine his body. We find the intestines 
sticking to each other, and also to the opposing surface, perhaps in 
an irregular manner, as did such portions of them, in the other 
case, as were in the immediate vicinity of the wound of the cavity. 
The surfaces of the intestine, as well as the extension of the same 
membrane (peritonaeum) which lines the walls of the cavity, are 
traversed, in various directions, by vessels exhibiting a redder ap- 
pearance than is natural. There is a good deal of yellowish, thin 
fluid effused into the cavity of the abdomen; and flakes of a 
yellowish, soft, and adhesive matter (coagulating lymph), varying 
in size, are adhering to the surfaces of the intestine, and to that 
to which they are opposed. This is, indeed, a state of things ap- 
parently very different from those in the case which did well, and 
still more so from the first case we supposed of a simple wound 
from a clean-cutting instrument. The one presented us with little 
more than a gradual and perfect restoration of the injured part ; 
the other produced effects far away from the local injury, and 
ended in the death of the individual. Yet they are but magnified 
views — literally, extensions of the same process. 

Now here I again caution you in regard to the wound being 
considered as the necessary cause of the sequences on it, and for 
the same reason as before ; namely, that all these sequences are 
seen to occur without any wound at all*. Again : you see that the 
wound has been the same, so far as we can perceive, in both cases ; 
yet how different have been the results ! A man may get wet in 
his feet, come home, shortly feel himself shivering and ill, and 
have inflammation of the peritonaeum come on, which is, in fact, 
what I have been sketching to you in the fatal case : yet here 



* So if T speak of universal inflammation of the peritonaeum, following what 
we call strangulated hernia— that is, where the aperture through which the intes- 
tine has protruded girds the intestine, embarrassing its circulation, and producing 
inflammation — the same remark applies. The truth is, that the same inflammation 
which followed the wound in the one case, and the mechanical violence consequent on 
the constriction or the hernia in the other, occurs in other cases, not only 
without a wound or a hernia, hut without any perceptible external impression 
whatever, although I am not forgetting that cold is an external impression. 



238 



again you have thousands get wet feet without any such conse- 
quences. All this must be considered. 

I may now, then, observe that these appearances, which I have 
marked as characterizing inflammation of the peritonaeum, present 
the type of the appearances which usually characterize inflammation 
of this kind of structure. We call it a serous membrane ; and we 
apply the same name to one of the membranes which invest the 
brain, the arachnoid (so called from its thin, spider's-weblike 
appearance), to the pleura, which covers the lungs and hues the 
chest ; to the peritonaeum, of which I have spoken, and which 
covers all the abdominal viscera ; to that which immediately in- 
vests the heart, the serous layer of the pericardium ; and to that 
which contains the testis. They are all capable of sticking toge- 
ther (adhesion), of producing pus (suppuration). Sometimes they 
simply adhere ; sometimes they pour forth pus without adhering ; 
and sometimes they exhibit a mixture of the two, as in the case of 
the wound of the belly : but we always observe a great tendency 
in them to stick together in inflammation ; and, as we observe this 
as an absolute character, and still more remarkably when we con- 
sider these structures in relation to others already mentioned, we 
say, when we speak of the tendencies of inflammation (termina- 
tions, as we technically call them), as modified by structure, that 
the tendency of serous membranes under inflammation is to 

ADHESION. 

So striking is this, that, for one case of inflammation of a se- 
rous membrane, presenting us with any other appearance than 
increased vascularity, and adhesion of its opposing surfaces, by 
eifusion of coagulating lymph, we meet with very many where the 
morbid appearances are confined to these phenomena ; and this, 
too, whilst exceptions are by no means so unfrequent as to 
be uncommon. The lungs are constantly found adhering, 
by means of their serous investment, to one or more points 
of the chest ; often universally adherent, the play of the lungs 
having apparently led to an elongation of the connecting 
media. Now we often, it is true, find eflusion of water or matter 
into the chest, with and without adhesion ; but then there is jio 
proportion in their frequency to the occurrence of adhesions. So 
with the heart : we find this organ adherent, either partially or 
generally, to the membrane which covers it. The connecting 
medium (lymph) is deposited in a variety of forms ; sometimes gra- 



' 239 

nulatecl, at others of a reticulated texture, and so on ; but we do 
not iind the other terminations of inflammation, except in rare 
instances, effusions of water only excepted. These, too, when the 
effusion can be properly set down as a morbid appearance — that is, 
as existing before death — are perhaps hardly so common as we 
imagine them to be. Adhesions, on the other hand, I apprehend 
to be much more so. As I must hereafter dwell more at length on 
these subjects, I will merely state that what I have observed with re- 
gard to one serous membrane, mutatis mutandis, applies to them all. 

We take advantage of this tendency to adhesion in some cases. 
When we wish to obliterate a cavity lined by a serous membrane, 
we have nothing to do but to excite inflammation (supposing that 
it can be done without danger), and the sides of the cavity adhere ; 
that is, the cavity is obliterated. I must, however, remark that 
there is another change to which serous membranes are quite as 
prone as to adhesion ; and this is opacity. It is important to recol- 
lect this, and chiefly for two reasons : the one a general one, the 
other referring principally to an individual organ. In many instances 
of disturbance about the head, the only testimony we discover of 
inflammatory action having existed is the opacity of the serous 
membrane of the brain. And in the eye, when vision becomes 
impaired by causes affecting the eye as an optical instrument, it is 
by the combined agency of the tendencies to adhesion and opacity 
which I have mentioned. Parts adhere together which ought to 
move freely and independently ; and transparent structures be- 
come opaque. Thus the pupil, which naturally enlarges and dimi- 
nishes according to the intensity of light, becomes fixed, by the 
adhesion of the membrane which covers it, to the capsule of the 
lens which is just behind it; and the capsule itself is rendered 
opaque, forming what is called capsular cataract. The transparent 
lens which the capsule encloses becomes also opaque (lenticular 
cataract) ; or the same thing takes place in the transparent cornea*, 
forming another and often a much more irremediable embarrass- 
ment to vision. The use of knowing all this is in the promptitude 
and vigour which it necessarily engenders when these parts are 
under inflammation. 

Another circumstance observable in inflammatory disturbance 
of serous membranes, is their disposition to effusion of aqueous 
fluid. Of this, water in the brain (hydrocephalus), in the chest 



* Which, however, is not a serous memhrane. 



240 



(hydro thorax), in the pericardium (hydrops pericardii), in the 
abdomen (ascites), and common hydrocele, are familiar examples. 
Still adhesion and opacity seem to be the leading primary disposi- 
tions. The joints are lined by a membrane, not perhaps identical 
with those which we call serous, but certainly presenting more of 
analogy with those than \\'ith any other structures ; and all other 
things (that is, the degree of inflammation and the persistence of 
disturbing causes) being alike, we find their dispositions under 
inflammation similar to those of serous membranes, but perhaps, by 
reason of the structures with which they are connected, not practi- 
cally exemplified so strongly. 

For reasons which will appear when I speak of the treatment 
of inflammation generally, I shall say a few words in regard to the 
management of its several processes now : and first of adhesion. 
The management of this process will be varied by the considera- 
tion that our object is sometimes to further its accomplishment, at 
others to prevent its occurrence. When Nature produces adhesion 
between parts, we observe — first, that they are in contact ; second- 
ly, that there is little or no motion between them ; and, thirdly, 
that the adhesion is certain and steady in proportion as the inflam- 
mation is of moderate character; that, if the inflammation be 
actually put a stop to, nothing happens bat resolution, — as some- 
times occurs in the chest and abdomen. 

\Ye further observe, that bruised surfaces will not unite like 
clean cuts ; but that the bruised surface must be changed ; and 
that bringing parts, which have sufl'ered an injury of this kind, into 
contact, is useless. If contact be the desirable condition for adhe- 
sion, then any intervening body must be e^adently calculated to 
retard or prevent that process. Hence all foreign matter, as gra- 
vel, glass, dirt, sutures of sUk, &c. must be removed, or dispensed 
with as much as possible. Now what we do in actual practice 
arises naturally and simply out of these observations of Nature's 
processes. All that farrago of balsams, &c. which infested the 
practice of surgery, and of which we see remains in farriery, is ex- 
ploded. When we wish to heal a wound by adhesion, or the 
"first intention," as it was technically termed, we bring parts toge- 
ther, whenever we can do so without stretching them ; and this, 
partly by position, partly by approximating the edges by sticking- 
plaster. We then apply a little cold water, if the part seems be- 
coming very hot, to regulate its temperature, and to keep the ex- 
citement moderate. If you chill a part, or entirely subdue inflam- 



241 



mation, adhesion will not take place ; because adhesion cannot 
occur without some inflammation. Then we remove all foreign 
bodies j and, for the same reason, never employ sutures, or sewing 
up of wounds, except it be where we gain more, as regards the 
whole wound, than we lose bj the foreign body we partially inter- 
pose ; as in hare-lip, and large wounds of the skin, where it is 
loose and abundant. 

Here the ordinary method of bringing the parts together by 
sticking-plaster is ineflicient, not affording sufficient resistance to 
counteracting forces, as the muscles in the case of hare-lip : there 
are also situations in w^hich plaster cannot be conveniently applied. 
In such situations, the bringing of the vround together in one or 
tw^o points, by means of a thread, will often enable us to bring the 
surfaces of the whole wound into contact — an advantage which 
more than counterbalances the interposition of a foreign body (the 
thread) at one or two minute points of it. We thus practically 
retain, in a few cases, such as those which I have mentioned, and 
in the analogous ones sometimes famished by accidents, the sutures 
of the old surgeons. Generally, we avoid them as much as 
possible. 

Mr. Hunter's experiments will furnish you with some interest- 
ing examples of adhesion, which (as you will of course read his 
works) 1 need not repeat here. The Taliacotian operation, that 
of making a new nose, is an application of adhesion. 

Some other phenomena, in connection with adhesive inflamma- 
tion, require to be noticed, because they shew^ that it has a preser- 
vative tendency ; and that the disposition to adhesion is most 
marked where it is most required. It is also interesting to observe, 
that, ecBteris paribus, all parts have an especial disposition to take 
on this process, when inflamed, in some proportion to the otherwise 
healthy condition of the oeconomy at the time. 

All inflammations on the surface of the body which we are 
accustomed to regard as healthy, — that is, as co-existing with an 
otherwise sound state of the system, — are attended by adhesion ; 
and, in inflammations which produce suppuration under such cir- 
cumstances, there is almost always adhesion at the circumference 
of the inflamed district. We infer the beneficial tendency of this 
arrangement from several facts ; but those which have more direct 
reference to inflammations at the surface are chiefly three : first, 
we see it exemplified in subjects who are the most healthy ; se- 
condly, we find that the inflammation does not extend beyond such 

R 



242 



adhesion ; and, thirdly, when no such adhesion occurs, we see the 
inflammation spread indefinitely ; involving, therefore, a greater ex- 
tent' of mischief, and frequently endangering, and sometimes 
destroying, life itself ; as in some examples of erysipelas. I should 
observe to you, that, however ignorant we may be of the exact 
mode in which inflammation becomes thus limited, by that which 
takes place in the circumference of inflamed parts being of an ad- 
hesive character, we know thus much : that the interposition of a 
different structure always seems to impede the progress of inflam- 
matory action ; in other words, that inflammation spreads more 
rapidly through parts of the same structure which are mechanically 
continuous than where the continuity involves parts of varying 
structure. Now, the adhesion of which I have spoken forms a new 
structure by the efliision of coagulating lymph. 

The adhesion of the surfaces of those membranes which line 
the important canals of the body tends to prevent inflammation 
from pervading the great extent occupied by them; and, at the 
same time, keeps the cavity shut. The fact, that the interposition 
of a new structure, or any other destruction of continuity, tends to 
arrest the progress of inflammation, is illustrated by certain facti- 
tious means, employed with more or less success, apparently on 
this principle. Sometimes the circumference of an inflamed part 
has been destroyed by caustic, or has been compressed by ligature ; 
producing, in the one case, an interruption of continuity ; in the 
other, a difl'erent condition of parts between those inflamed and 
those not yet affected. When parts are united by adhesion, which 
have been forcibly separated by incision, and subsequently brought 
together, it has been made a question, whether the vessels at once 
unite, or do so by the previous interposition of coagulating lymph ; 
but to say nothing of the fact, that the determination of this ques- 
tion seems very unimportant, even were it in our power, there ap- 
pears no reason for supposing that adhesion takes place, in this in- 
stance, by means at all different from those by which it ordinarily 
occurs. A clot of blood may be the temporary medium, or it may 
be the nucleus for the organization which, in other cases, is de- 
veloped in the coagulating lymph effused. But, as Mr. Hunter 
observes, the leaving blood in the wound is not necessary ; in fact, 
it is to be regarded as " rather immaterial advantageous ;" since, 
the coagulating lymph being the part of the blood required, it ne- 
cessitates the removal of the other constituents of it, which is the 
superaddition of a process in itself unilfecessary ; and, as it may 



243 



be allowed to escape through the wound, it has, as far as it goes, a 
tendency to separate it ; whilst, if it be absorbed, it is imposing an 
unnecessary duty on the part. 

Mr. Hunter proved that the coagulation of effused blood be- 
came, in certain cases, the nucleus for new organization, by inject- 
ing vessels going into it. This was doubted by many, notwith- 
standing that there is a preparation which demonstrates the fact. 
However, last year, there was a recent specimen, proving this fact, 
shewn at one of the meetings of the Royal Medical and Chirurgical 
Society. I shall only add, that, when surgeons wish to ensure ad- 
hesion, the chief things to be regarded are, proximity of the parts 
it is proposed to unite ; inflammation, extremely moderate in de- 
gree ; and as healthy and tranquil a condition of the oeconomy as 
the particular circumstances place within his power. 

The Taliacotian operation has been before mentioned as afford- 
ing an instance in which the process of adhesion is made available 
in practice. A brief description of this operation may not be im- 
proper. The integuments are first dissected off from the district 
which had been occupied by the nose ; a piece of skin, of a size 
and form calculated to fit the raw surface, is now dissected from 
the forehead ; and, being separated entirely, except by a small slip 
towards the nose, is turned downwards, and applied to the surface 
above mentioned. The parts adhere, and, in many cases, the pre- 
vious disfigurement is rendered much less remarkable. 

What is called the radical cure of hydrocele is also a good ex- 
ample of adhesion. Fluid collects in a cavity lined by a serous 
membrane ; we let out the fluid ; we inject port wine and water, 
or some other stimulant, to produce inflammation ; and adhesion 
of the bag takes place ; its cavity is obliterated. 

If the inflammation appear to be wholly subsiding, we make the 
patient move about, to favour its excitement ; if it threaten to be 
severe, we enjoin rest, and adopt other measures to moderate it (as 
you will see in the proper place), and we seldom fail to produce 
the result we desire. If, on the contrary, we wish to prevent ad- 
hesion, we do just the contrary of all this ; so far at least as is 
necessary for the purpose : but this is very simple, for the only 
measure necessary is, to keep the surfaces from coming into con- 
tact. Setons, and, in a modified sense, issues, are examples of 
this. Nature makes a sort of issue herself, in many cases ; and 
one way in which she accomplishes it, is, by forming a canal 
(fistula), and lining it with a structure, not distinguishable from 

R 2 



244 



a mucous membrane ; the propensity of which, under inflammation, 
is, as jou know, to suppuration, not adhesion. 

SUPPURATION. 

Our endeavours at the promotion or prevention of a tendency to 
suppuration resolve themselves respectively into measures calculated 
to arrest or continue the inflammation. Thus, where we wish to pro- 
duce suppuration, we adopt measures of an irritating kind ; and when 
we wish to prevent it, we resort to those of a contrary character. 
The latter refer to that mode of proceeding which will be spoken of 
in connection with the general treatment of inflammation : the 
former usually involve those which stimulate the part. Practically, 
our interference, with regard to these objects, is governed by the 
nature of the situation in which the process occurs. On the sur- 
face of the body, we seldom interfere very actively to prevent any 
tendency to suppuration ; the surface of the e^ e only excepted ; 
whilst, in all other parts of this organ, and in every organ or sur- 
face of the interior of the body, we know that suppuration is in the 
highest degree dangerous ; and, therefore, our utmost endeavours 
are always employed to cut the inflammation short of producing 
this process. On the surface of the body we interfere, as I have 
said, but little ; aud when the tendency to suppuration is unequi- 
vocal, our endeavours, almost without exception, are directed to 
relieve the pain, and to expedite the discharge of matter. When 
the process goes on without disturbance, we content ourselves by 
regulating the temperature of the part ; and this chiefly by the 
application of poultices. If the action be vehement, we put on an 
evaporating poultice of bread and water, which regulates the tem- 
perature, and eases the patient, without interfering with the sup- 
puration; whilst, if the case be doubtful, as to the suppurative 
tendency, it is a measure essentially anti-inflammatory, as carrying 
off heat from the part, and in facilitating the tendency (and, in fact, 
often determining it), to resolution. On the contrary, if the in- 
flammation be indolent or stationary, and we desire to determitie 
the action to suppuration, a greasy poultice is a better application ; 
for it is soft, and comfortable by its warmth, and does not tend to 
repress the attempt at suppuration by abstracting heat from the 
part. It is important to distinguish between these intentions in 
applying poultices. Mr. Abernethy knew and taught their im- 
portance ; but I am sorry to observe, that little attention is paid. 



245 



in many instances, to the very simple and obvious distinctions 
on which he very properly used to insist, with respect to these 
applications. We now see all sorts of poultices employed indis- 
criminately, as if heat and moisture, evaporation, &c. were nothing, 
instead of being agencies through which some of the most im- 
portant laws of Nature are manifested. 

ULCERATION. 

When the discharge of suppuration is not immediately and pro- 
gressively followed by the healing of the wound of the surface, 
Nature does one of two things. If the matter continue to be se- 
creted from any depth, she forms a pipe for its conveyance to the 
surface. She lines this pipe with a smooth, secreting surface, from 
which matter is elaborated ; and we call the canal thus formed, a 
fistula. If, however, the matter have not to travel from any depth, 
and the surface do not heal, we have a surface without skin, pre- 
senting very different appearances in different cases ; and this we 
call an ulcer. Now^ all ulcers have some characters in common, 
and it is to these that I would particularly draw your attention. I 
will first, how^ever, discuss what appears to me to be a much less 
important subject, — namely, the points in which they differ. Some 
have smooth and even surfaces ; their surface is also red, and if 
examined carefully, even by the naked eye, seems to consist of a 
congeries of pointed processes (granulations), over which there is 
observed a very thin, semitransparent coating, of a soft, and, in 
appearance, semifluid, mucus-like secretion (lymph) : if w^e look 
at the edge, we find it smooth and level, and surrounded by a very 
minute halo of vascularity. I mean that there is a fine line around 
the ulcer, of a brightish red colour. If we examine this ulcer once 
a-day, we find that it exhibits a secretion, answering in its charac- 
ter to healthy pus. There is a faintish, mawkish odour ; but we 
do not recognize it as foetid. 

If the ulcer be healing, there is, in addition to these appear- 
ances, an opaque, delicately thin, and apparently levelled margin 
in its circumference, which is a fine film of new skin, or that which 
is to become so. These are the characters of what is called a 
healthy ulcer. All the circumstances which I have mentioned 
may exist, with the exception of that last adverted to. In other 
words, — the sore may be, in other respects, not demonstrably other- 
wise than healthy ; and yet it will not heal. More commonly, 



246 



however, when au ulcer cannot be brought to heal, there is an ob- 
vious departure from the above characters. Such departures may 
exist simply, or may occur in every conceivable combination. 
The circumference may be irregular, oblong, jagged, or of any va- 
riety of shape ; the edge may be thick or undermined ; the surface 
may be white, yellow, smooth, or shreddy and ragged ; the dis- 
charge may be thin, bloody, watery, or highly offensive, acrid, and 
stimulating to the surrounding skin. The sore may be unusually 
excavated, forming a circumscribed cavity ; or it may be super- 
ficial in one place, and deep in another. There may be no granu- 
lations perceptible ; or if there be, they may be round, obtuse, 
flabby, or purple ; the surrounding redness may be more highly 
developed in extent, or darker in colour ; the sore may also be 
extremely painfal. Sometimes we observe granulations form in the 
centre of an ulcer ; and, becoming covered by skin, form little 
islands as it were in the sore. 

Now these various appearances, when met with in certain 
states of combination, have led to the application of certain names 
to ulcers which present them. When the sore is mieven on its 
surface, jagged at its edges ; when it secretes a serous, sanguineous, 
or ichorous discharge ; and when it is painful ; we call it irritable : 
by which, practically, a disposition to increase is generally under- 
stood. If you stimulate it strongly, it is apt to slough or to in- 
crease by ulceration. xApplications, unless of the most soothing 
kind (by which I mean those, the object of which is chiefly con- 
fined to the regulation of temperature), are apt to give pain, and 
the sore shews no disposition to heal. If the granulations are large, 
grey, flabby, and inactive, we say that the sore is indolent ; because 
there is not the same marked departure from the actions of a 
healthy sore, and because such sores are sometimes found to progress 
favourably under applications which, we believe, act in virtue of 
their stimulating, strengthening, or exciting qualities. 

For the most part, how^ever, the various characters of ulcera- 
tion which I have mentioned, are combined in such interminable 
variety, that we soon find any attempt at a nomenclature of them 
useless. Yet, in a few instances, on the contrary, ulceration seems 
to preserve a certain uniformity of character ; which, inasmuch as 
the resemblance is maintained in different individuals, we con- 
clude to depend on some peculiar or specific circumstances. Such 
is more or less the case in syphilis, cancer, and scrofula. Thus 
we speak of syphilitic, scrofulous, cancerous ulceration, and so 



247 



on : all of which, you perceive, must be more fully treated of in 
connection with the respective subjects. I wish }^ou, then, to 
observe, that the surfaces of sores, inasmuch as they enlarge in 
breadth and depth, shew the existence of absorbents ; and that 
they have blood-vessels, in that they diminish, fill up, and heal, 
and their surface is sometimes extremely vascular : that the pain, 
and various sensations by w^hich they are attended, shew that they 
have nerves ; and that, iu fact, an ulcer has obviously all the cha- 
racters of a li\ing part. 

In linking ulceration with that production of inflammation which 
we call suppuration, we observe no difference between them, except 
that suppuration is commonly a process which terminates more or 
less quickly in healing ; whilst, in ulceration, the suppuration is 
continued, as also in the case of the fistula of which I have spoken, 
for an indefinite period, with the superaddition of a new structure, 
exhibiting phenomena which we agree to call ulceration. Now 
this is all I wish you to recollect for the present ; because, like all 
other subjects, this must of course be treated more fully by itself ; 
and what applies to it in connection with inflammation, I shall 
consider as we proceed. 

MORTIFICATION. 

I shall hereafter be obliged to speak again of mortification, in con- 
nection with other subjects ; but it is necessary that I should, in con- 
nection with inflammation, at once give you a general notion of the 
subject. You must not imagine that mortification simply implies a 
loss of vitality ; because, if you look at a limb in a dead body, and 
what we call mortification in the living, you will see no similarity. 
To this there is, indeed, one exception, presently to be mentioned : 
but what I intend, with regard to mortification in general, is, that it 
is a peculiar process, — a process, in fact, of life ; — and for this 
reason, we never see it in anything but a living body. When in- 
flammation is to terminate in mortification, we always find that the 
inflammation is very vehement in degree, and seldom healthy in 
character ; that is, it is diffused* ; there is no line of demarcation 



* This is true, eveo in boil, carbuncle, &c. ; which become, in relation to 
circumscribed and diffused inflammations, most interesting links as connecting 
the chain of diseased phenomena. For there is, in all of them, an attempt at 



248 



to it until mortification lias begun : it is, in fact, allied in its cha- 
racter to erysipelas. When a portion of living structure mortifies, 
we observe, first, that the scarf-skin (and I speak of the skin be- 
cause we have no opportunity of seeing what happens anywhere 
else) separates from the skin (blisters or vesicates), and the skin 
itself becomes, in various cases, yellowish, brownish, — in some cases, 
greenish, and ultimately, perhaps, dark, or even black, in colour. 
When it is finally thrown off, it is not in the least like the natural 
structure ; whatever of organization there was in it seems some- 
how or other to have been destroyed : and I hold this to be a very 
curious thing. It is not the decomposition of putrefaction, that 
appears certain ; so whether it may have wrought some change in 
itself, or whether any material of value to the system has been ap- 
propriated by the absorbents, and the curious appearance which we 
observe be consequent to its subtraction ; or whatever may have 
been the cause ; at all events, a distinct process has taken place, 
and one which, in regard to the power wliich exerts it, must be 
regarded as vit&l. All other things being alike, the probability of 
mortification is in proportion to the degree of inflammation ; but 
then this is too general and vague a rule to be of much use in 
practice. The structure of the part, and the kind of inflammation, 
are the essential things to know ; for these are the chief sources of 
our information, as regards tlie part, as to the probability of morti- 
fication taking place. Inflammations which are attended by violent 
actions of the system or part, with but little power, are very prone 
to terminate in this process ; and the same may be said of inflam- 
mation attacking parts endowed with small vessels or few nerves, 
or both, as bone, ligament, fasciae, fibrous and ligamentous struc- 
tures, generally. In destructive inflammation of the eye, the 
cornea, the vessels of which are very minute, is generally the first 
part to slough. Sloughing, gangrene, sphacelus, and mortification, 
are all convertible terms : though I hardly know that any of us 
agree in their exact definition. When we see portions of dead 
substance thrown off from a surface, although active inflammation 
continues in the circumference, we generally say that the surface is 
sloughing. When a considerable portion loses at once its vital 
power, and takes on the appearance which I have before mentioned, 



localizing the inflammation ; the success being greater or less in different cases, 
but scarcely complete in any, the redness generally extending more or less 
indefinitely around the more immediate seat of the disease. 



249 



we say it is gangrenous ; and when the changes are carried so far, 
that the whole limb becomes dark or black, we usually employ the 
term sphacelus. There is one very curious kind of gangrene or 
sphacelus, in which the change really appears to consist in the 
simple abstraction of life, and in which a limb presents very little 
difference, if any, from one which may have lain some days in the 
dissecting room. All other exemplifications of mortification are 
attended by the production of some quantity of moisture ; this is, 
therefore, sometimes called dry gangrene. It has been found, in con- 
nection with ossification of arteries, and other morbid conditions of 
the circulatory apparatus. Wherever mortification of any kind oc- 
curs, and the patient recovers, there are certain changes that take 
place, which are common to every variety. The parts subjacent to 
the line between the mortified and sound structures, are removed by 
absorption ; and thus the part to be got rid of becomes isolated 
from its connections ; always, however, having by this time under- 
gone a very remarkable alteration in appearance and structure. 
Now, then, if we wish to prevent inflammation from terminating in 
mortification, we act on the suggestion naturally arising out of its 
phenomena. That is to say, that as we observe mortification seldom 
to occur without violent inflammation, the way to avoid it is to 
prevent the inflammation from being violent : and we characterize 
this endeavour differently, as regards the mode or its activity, in 
proportion as the vehemence actually present receives additional 
force, either from the kind of inflammation, or from the peculiarity 
of the structure in which it is seated, or the causes on which it may 
depend. This is all I need say just at present ; except that, m any 
measure you may adopt to reduce inflammation threatening to 
terminate in mortification, you must recollect that mortification 
never occurs, except it is occasioned by direct injury, without im- 
plying a combination, which is always an element of difficulty in 
the treatment of every disease ; that is, great excitement with dis- 
proportionate power. You will see hereafter that there is no 
single phenomenon in any one of the steps which Nature pursues 
in inflammation, which may not be rendered of great use in the treat- 
ment of diseases. It is with her a process through which a multitude 
of effects are produced, and one by which we may effect changes 
in a number of maladies ; and which, if the causes which produced 
them be attended to at the same time, leads to their safe removal. 
Thus, if w^e wish to get rid of a new structure, we may often effect 
changes in it which either bring it within the pale of some of our 



250 



other modes of proceeding, or which of themselves remove it. 
The mode in which I successfully removed, as I believe, for the 
first time, a peculiar kind of deep-seated vascular tumour, some- 
times called aneurism by anastomosis, or deep-seated nsevus, was 
suggested by a consideration of what Nature does in various ex- 
amples of inflammation. Superficial or subcutaneous nsevi had - 
been often removed in various other ways ; but the first successful 
removal of this kind of disease, involving a peculiar depth and 
extent of connection, was effected in the cases to which I have 
alluded, and which you will find in the eighteenth volume of the 
Transactionss of the Royal Med. Chirugical Society. 

Mortification, then, occurs as a sequence on violent inflamma- 
tion ; and it also occurs, in rare cases, without, so far as we can 
see, the previous occurrence of violent inflammation, as in the dry 
gangrene. Ordinarily, therefore, mortification requires some little 
time for its occurrence ; but it is to be remembered, that it may be 
preceded by the ordinary inflammatory process, and yet may be 
carried on with such rapidity as to justify the phrase, " the part 
suddenly mortifies." I met with a case of this kind, which, all 
circumstances considered, was very extraordinary. A young man, 
aged thirty-four, by occupation a brewer's drayman, went to bed, 
periectly well, as he said : this was about nine or ten o'clock. He 
awoke very early in the morning, about two or three o'clock, with 
a most violent pain in the finger, which already appeared very dark, 
and in one part black. I saw him at one o'clock the same day. 
Had any person seen the finger of this young man thus, not twelve 
hours after the first attack, he would have regarded the change as 
the work of at least several days. The first phalanx of the fore- 
finger was completely mortified, and thoroughly black ; and the 
corresponding phalanx of the middle finger seemed rapidly ap- 
proaching the same condition. 1 found, too, that his habits were 
very different from those of the generality of brewer's draymen, 
most of whom drink large and almost incredible quantities of beer ; 
but this young man said he could not do it ; and this I afterwards 
had reason to know to be true. I never saw a nervous sj'stem in 
such a condition. Every fibre in his body seemed in a vibratory 
action. Pulse rapid and bounding ; the patient complaining that 
he felt very ill, &c. He lost the first joint of his fore-finger ; but 
ultimately got well. He is still alive ; but his nervous system is 
exceedingly deranged. Since tlie attack of mortification, he has 
been very ill with a strange set of symptoms, threatening dropsy. 



251 



and attended by tlie ordinary features of severe salivation, exhal- 
ing even the odour peculiar to that condition, but without having 
taken any mercury. He rallied, however, from this state. I may 
state that liis circulation is always in a much disordered condition ; 
and that the organ most prominently out of order is always his 
liver. He is fat, and altogether what I suppose would be regarded 
amongst drayman as the beau ideal of the craft. 

There is, likewise, a species of mortification in which ulceration 
and mortification are combined, and which is in the highest degree 
intei'esting, as shewing, in its varying indications, the alternations of 
success and failure in the powers of the animal oeconoray. 

In one description of these cases (for I can only speak of what 
I have seen), a patient is presented to you with an immense sore, 
occupying, perhaps, half the leg below the knee. It is deep, and 
presents, in many parts, a yellowish, sloughing surface ; whilst, in 
others, it is merely that of ulceration ; and is in some covered by 
florid, and even not unhealthy-looking, granulations. The dis- 
charge, however, is usually more or less thin and ichorous ; and it 
exhales a most peculiar odour. The only character of this, that I 
can mention, is, that it is highly offensive, with the superaddition of 
a property which seems allied to acidity ; and, if you examine it 
closely, and for some seconds, so as to breathe air much impreg- 
nated with it, that it seems slightly to embarrass respiration. At 
least this is the case with me, who, for many years at least, could 
breathe almost anything. I may observe, that you seldom or never 
get this kind of sore to heal, although it often flatters you by an 
appearance of so doing ; and, indeed, it may actually heal to a 
considerable extent. It generally occurs in old people, but is, in 
appearance, altogether different from that mortification which takes 
place in the toes and feet of such persons ; nor does it occur in 
persons whose powers are so exhausted. For, although, as I have 
said, the cases seldom heal entirely, yet I have known persons a 
year or two, or even more, with such sores ; though they seldom, I 
think, go on longer than that, — gradually sinking without there 
being any remarkable difference in the sore. 

Another variety of mortification, though perhaps differing very 
little in its essential causes from the foregoing, takes place in a small 
district. A sloughy spot appears, the slough separates, and the part 
begins to heal ; but, as it heals, another portion of skin begins to 
slough, and so on ; the patient in the end sinking. Mr. Abernethy 
used to tell a very interesting case of this land. The most remark- 



252 



able one that I recollect of it occurred in a very fine man, who had 
been confined a very long time by an accident, the consequence of 
which was, that he lost his exercise without making corresponding 
changes in his mode of living, in anything like the requisite pro- 
portion. Just as he was getting about, a small spot of slough oc- 
curred in his foot, which he attributed to an uneasy shoe. It was 
very small, and presented nothing very different from what I have 
stated. In colour it was yellowish, and slowly separated in the 
usual manner. Before the sore healed, however, his powers sud- 
denly sank, and he died. I mention these cases at once (though 
I cannot go fully into the subject), for two reasons ; first, as im- 
pressing the different varieties of mortification to which they refer ; 
and, secondly, as inculcating a caution in regard to prognosis ; for 
really we see these cases, with such local manifestations of repara- 
tive power, co-existing w^ith a countenance exhibiting so little 
indication of approaching failure, that, without caution suggested 
by experience, we might well be excused for expecting, and there- 
fore for representing to the friends of the patient, happier results 
than our best-directed endeavours in such cases usually enable us 
to obtain. I may observe that, in some examples of mortification, 
it is very common to find that the blood is coagulated in the large 
vessels, beyond the mortified part, constituting evidence of inter- 
rupted or embarrassed circulation, on a certain freedom and vigour 
of which the preservation of the life of parts essentially de- 
pends ; and this is all I think it necessary to observe at present on 
the subject. 

THICKENING. 

I have hitherto considered those processes of inflammation 
which we call resolution, adhesion, suppuration, and mortification, 
because they are the sequences which are usually first mentioned 
as those of inflammation. There are, however, some others, con- 
cerning which it is necessary that we should consider a few circum- 
stances, before we treat of the causes of inflammation, whether im- 
mediate or remote ; and one of these is thickening. 

If we regard the result of the thickening process, and that of 
the adhesive, we can perceive little similarity between them ; yet 
they are, in truth, not so different as their results would lead us to 
imagine. There is more or less coagulating lymph effused when 
parts become united : this becomes vascular, and assumes the cha- 



253 



racters of the parts wliich it unites. Now, thickening is little more 
than an increased degree of this. We have no reason for believing 
that the matter first effused is other than coagulable Ijmph ; and 
we know that, as regards its becoming vascular, and assuming in 
general the characters (and, in many cases, identically so) of the 
part, the result is the same. Thus, if a bone, ligament, tendon, 
fascia, or membrane, become thickened, we discern no difference 
necessarily from the ordinary characters of the part, except that 
which the thickening itself constitutes, or which may be reasonably 
referred to it. The part may be less elastic, or it may be less 
transparent; but this may happen equally with a piece of any 
elastic material, such as Indian rubber, for example. Increase of 
bulk is, of course, implied in the term tliickening ; and inconve- 
niences, in the execution of function, occur from this circumstance. 
It is further important that you should be impressed with the fact, 
that this thickening usually results not from violent, but -from en- 
during, excitement ; and, as the vessels of a part are seldom ex- 
cited without doing something, it is interesting to observe, that the 
products of this sort of inflammation are generally deposited under 
such a modifying action of the part, that they gradually assume the 
structure of it ; in other words, the product is deposited in a form 
least injurious to the function of the part which it occupies. 

To estimate this, we have only to imagine that it were other- 
wise ; that the matter of bone were deposited in muscle ; and vice 
versd. Indeed, we sometimes see a practical exemplification of 
this departure from the more salutary mode of proceeding ; and the 
result is always a much greater deterioration, and frequently a 
complete abrogation, of the function of the part in which such 
deposition occurs. This leads me to remark on such exceptions to 
the more ordinary effects of chronic inflammation. Of these, we 
may first speak of such examples as may be referred to a kind of 
misplacement of products natural to the oeconomy, as when bone 
is deposited in ligament, fasciae, tendon, or in the arteries or mem- 
branes, and, I might add, other parts ; for, although these parts, 
amongst those which are not naturally of an osseous character, 
are the most frequent seats of osseous deposition, yet bone may 
be deposited anywhere. So, on the other hand, ligamentous struc- 
tures may be deposited in boiie ; and it is also interesting to remark, 
that, where ligament best supplies the place of bone, there we find it 
most frequently thus deposited. Thus, where bones have to sup- 
port weight — a function for which ligament is obviously altogether 



254 



unadapted — we very rarely find it deposited, ununited fractures 
being almost the only examples of such deposition ; whilst, where 
a bone is merely a point on which some power pulls, it is an every- 
day occurrence, as we see in fractures of the point of the elbow 
(olecranon), and the knee-pan (patella). 

But this, however, is but a hint cn a very important subject. 
An exception is apparently suggested in the common results of 
fractures of the neck of the femur within the capsular ligament — a 
subject which will be fully considered in its proper place ; and a 
capital example of the numerous departures from legitimate modes 
of induction, which have contributed so much to retard the progress 
of science. The true reasons of ligamentous depositions will then, 
I trust, be made apparent : but I must now proceed with the gene- 
ral subject. 

The results of increased action in a part sometimes present 
still greater aberrations than any of those yet mentioned, in that 
the products which they deposit are altogether strange, and like 
nothing else that w^e see in the animal oeconomy ; but in this they 
are little different from common pus or matter, w^hich is alike a 
new product. Thus, various structures, of every conceivable diver- 
sity of physical character, are occasionally deposited ; so that they 
considerably alter the form of parts, and destroy the symmetry of 
the body by the unsightly projections which they constitute. This 
happens in regard to tumours, as we call them, which do not always 
form in a very slow manner, though this be their general character. 
Why I refer them to chronic inflammation will be more spoken of 
as we proceed ; but I may here mention, that there is not more 
difference in the excited action demonstrable in some examples of 
tumour, than there is between some kinds of chronic inflammation, 
which we acknowledge to be such, and other more marked exam- 
ples of active inflammatory action. Besides, we have no idea of 
any new product taking place, without an increased action of the 
vessels of the part ; and, as it will be seen that this is the essential 
thing in all inflammations, regarded as the proximate condition 
necessary — although in neither the one case nor the other are we 
to regard it as the cause — as I shall in due time explain. 

I must beg the reader to recollect that my object is not confined 
to writing a treatise on inflammation ; and that, therefore, until I 
can apply the w^hoie of its phenomena in the consideration of dis- 
ease, I must rest satisfied with the statement of elementary facts and 
principles, as far as it is necessary to give the ground -work of 



255 



the subject ; and so far as it may be necessary to enable you to 
understand me when I proceed, as I presently shall do, to consider 
the law to which its multiform phenomena refer. The facts, then, 
which I wish to impress in regard to what we term chronic inflam- 
mation, are, that the term, in its necessary and conventional accep- 
tation, merely refers to certain unnatural actions going on in a part, 
and attended by some new product ; and that the employment of 
the term arises, not unnaturally, from the following considerations. 
We begin by regarding inflammation as the co-existence of heat, 
redness, pain, swelling, &c. and as usually leading to certain pro- 
cesses, called adhesion, suppuration, ulceration, mortification, &c. ; 
but as we trace it through its various degrees, and as aff'ecting 
various structures, we find it to link with a variety of actions, mo- 
difying, very materially, the disposition with which we commenced, 
until at last, as in some abscesses, the production of pus or matter 
is the only character remaining of those which we originally at- 
tached to it. Pursuing the chain, which I am supposing to have 
been thus traced, and which I shall trace for you more particularly 
as we proceed, we find that depositions of various kinds take 
place, which again have nothing in common with the inflammation 
with which we commenced, except the deposition of new matter ; 
which is, in fact, a convertible term with " new action." No 
deposition can take place without action in the vessels ; and thus, 
inasmuch as these new depositions retain one, and that the most 
essential, character of inflammation, so we retain the word inflam- 
mation, adding the epithet chronic, as marking its comparatively 
slower progress ; and (by a conventional extension) the absence or 
feeble development of its leading characteristics, as pain, redness, 
&c. : but we can by no means mark the line which divides the 
formation of pus, the result of slow and chronic forms of increased 
action, from the production of this matter, by the milder forms of 
inflammation, in its more common acceptation. Neither can we 
mark any line (as regards the degree or the kind of excitement) 
which divides those cases in which pus is produced with the smallest 
quantity of perceptible excitement, from those cases in which de- 
positions of various kinds of tumours take place. We alike infer 
the action in both cases from its products. Then again, in some 
tumours, we have much more visible evidence of excitement than 
we have in many cases where pus, an acknowledged product of 
inflammation, is nevertheless secreted very largely, as in certain 
forms of chronic abscess. 



256 



It wiW be advantageous now to take a retrospect of the pheno- 
mena we have collected, to which I will then add such others as 
may appear necessary, in order that you may be able to proceed 
with me. We have seen then — 

1. That inflammation, in its u^ual definition, implies co-ex- 
istence of heat, redness, pain, swelling, and throbbing ; and that 
it is in fact often, but not invariably, accompanied by these phe- 
nomena. 

2. That when parts are separated by local injury, and are 
again placed in contact, re-union of them frequently follows, and 
that this process takes place by the effusion of coagulating lymph 
from the divided surfaces. 

3. That the contact of inflamed surfaces produces adhesion in 
parts where no wound had been inflicted. 

4. That, in other cases, the union takes place after the previous 
secretion of matter or pus ; by the subsequent deposition of new 
parts, called granulations ; and that in an ulcer, which is to heal, 
the granulations become gi'adually covered, from circumference to 
centre, with a fine pellicle, which ultimately assumes- the nature of 
skin. 

o. That when the wound imites, a contraction takes place, so 
that the scar is mucli less than the wound, of which it marks the 
situation. 

6. That, in some cases, the inflammation extends widely from 
the part, involving considerable and extensive destruction of sur- 
face ; the constitution becomes disturbed ; but still the original 
wound, and the parts destroyed in consequence of the inflamma- 
tion, ultimately heal, though slowly, and through a tedious and 
painful process. 

7. That in other cases, again, the parts destroyed do not heal, 
nor the wound which preceded the inflammation ; but that, the 
constitutional disturbance continuing, the patient sinks, in a condi- 
tion not distinguishable from typhus fever. 

8. That the products of inflammation, which we regard as ter- 
minating in suppuration, are various ; one of these being pus or 
matter, to the more common, and, as we believe, more healthy 
species of which we attach certain distinctive peculiarities. 

That the occurrence of any of the terminations of inflam- 
mation, as we conventionally designate them, may take place in 
any of the structures of the body ; but that, ccekris paribus, these 



257 



these terminations seem to be influenced in their character bj the 
structure of the part aifected. 

10. That, as regards inflammation occurring in the skin, cellu- 
lar tissue, or at the surface of the body, the terminations seem to 
be chieflj influenced bj the degree of the inflammation ; except 
that we remark in the skin (no matter whj, at present) a tendency 
to suppuration, though not perhaps so strongly marked as in mu- 
cous membranes. 

IJ. That the whole of the mucous membranes of the body, 
(parts in continuation with the skin), manifest a very obvious ten- 
dency to suppuration when inflamed. 

12. That, on the contrary, serous membranes manifest a great 
tendency to adhesion. 

13. That, in regard to certain consequences following the inflic- 
tion of a wound (apart from the healing of the w^ound), whether 
this have been confined to the surface of the body, or whether it 
involve a cavity like the abdomen, and ^whatever may have been 
their relation to the wound inflicted ; they all take place in the 
same structures, on other occasions, independently of any pre\4ous 
local injury. 

14. That a continued suppuration sometimes follows, and co- 
exists with inflammation, which alters the structure of the part, and 
which we call ulceration ; that the secretion, however, may be the 
pus we first described, or any of its varieties. 

15. That another form, in which suppuration is continued, is 
by the production of a fistula or pipe, which is lined by a secreting 
surface, and one possessing the general characters of a mucous 
membrane. 

1 Q. That one effect of inflammation, not essentially difli"erent, 
perhaps, from adhesion, is the thickening of parts affected by it. 
That, most commonly, this thickening partakes, more or less, of 
the natural character of the part, and sometimes is identical in 
structure with it. 

17. That, in the departures from this rule, the matter deposited 
is nevertheless generally similar to some other known structure ; as 
when bone is deposited instead of ligament ; in the ossification of 
arteries ; or w^hen ligament is deposited in place of bone. 

18. That, however, the newly deposited matter may be alto- 
gether new, and not only unlike the part on which it is deposited, 
but unlike any other structure in the body. 

19. That various tumours are exemplifications of this, espe- 

s 



258 



ciallj those which are deposited in, as contradistinguished from 
those which are deposited on, a part. 

20. That chronic inflammation implies slow progress of action, 
the result of which is a product not different from some of those 
resulting from ordinary inflammation ; but that the term is ex- 
tended to cases in which little remains of the character of inflam- 
mation, but that which is most essential, viz. increased action. 

21. That mortification is a sequence of inflammation, or a kind 
of inflammation in which certain parts entirely lose their natural 
characters, become wholly disorganized, and isolated from the sur- 
rounding structures, 

22. That, with one exception, we can hardly presume that this 
is simple death of parts, in its ordinary sense, because the dead body 
does not present us with corresponding phenomena : that it is, in 
fact, a peculiar change, whatever its nature may be. 

23. That there is no part of the body but which may become 
inflamed. 

24. To these, I may add, that as difl"erent parts have been seen 
to be more or less prone to this or that termination of inflamma- 
tion, so it is equally ti'ue that inflammation, as a whole, is much 
more frequently seen in some structures than others. For the mo- 
ment, one example of this will be suflicient ; namely, the skin, 
wherein iuflammatiou more frequently occurs, in some form or 
other, than in any other part, or than in all other parts put together. 

Before I begin to make use of our phenomena, I must say 
something in regard to what has been called the proximate cause 
of inflammation. This is a subject which I should have been glad 
to have avoided, as one most unprofitable ; liut, in the first place, 
I should ha^'e ofiended the prejudices of many people, had I passed 
it over ; and, in the second, it is a subject on which many erro- 
neous notions prevail, from which the mind must be disabused, 
before it can pursue the subject of the real causes of inflammation 
w^th advantage. 



259 



DISCOURSE VII. 

ON THE CIRCUMSTANCES ON WHICH THE OBVIOUS CHARAC- 
TERS OF INFLAMMATION, AS HEAT, REDNESS, ETC. DEPEND, 
COMMONLY CALLED THE PROXIMATE CAUSE OF INFLAM- 
MATION. 

In considering, farther, tlie actual condition of a visible part 
affected bj ordinary inflammation, I should, were I to follow my 
own inclination, restrict myself entirely to those circumstances 
which are obviously deducible from its physical character ; because, 
as regards any information derivable from the part, I consider that 
the inspection by the unassisted eye conveys to us just as much 
information of which any practical use can be made, as all or any 
of the experiments which have been made on living animals, either 
with assistance of th^ microscope or otherwise : but I can scarcely 
hope that my readers will be so wholly freed from preconceived 
notions on this subj ect, as to be satisfied with such a mode of treat- 
ing it ; nor could I even assist (however humbly) to the removal of 
erroneous and unprofitable modes of investigation, without testing 
the real value of their results by other and more tangible modes 
than passing them altogether unnoticed. 

Boerliaave thought that in inflammation there was a state of 
blood in which that fluid became altered in quality, and moved 
slowly through the vessels ; and that the red globules became im- 
pelled into vessels in which they were not naturally designed to 
move. CuUen thought that inflammation resulted from a shutting 
up by spasm of the minute vessels of a part, and that inflammation 
consisted of an endeavour to overcome this spasm by an increasing 
momentum of the circulation of the part. Vacca had a theory 
of inflammation, w^hich referred it chiefly to a relaxed state of the 
vessels. 

All these theories suppose that there is obstruction to the circu- 
lation : now, supposing this to be admitted, and any of the various 
explanations allowed, we are really not at all advanced in our 
actual knowledge on the subject ; — but of that presently. Mr. 
Hunter went differently to work ; but still not, as it appears to me, 

s 2 



260 



in the best manner ; yet. certainly, as regarded the ascertainment 
of the actual condition of the part, his mode was, perhaps, more 
promising. But the real knowledge of the subject is not to be 
obtained hy such modes of investigation. The knowledge required 
being, as I shall shew, not what produces the appearances in the 
part, but the process as a whole. However, Mr. Hunter proved 
several important facts by experiment : — first, he satisfactorily 
shewed that the arteries winch distribute the blood had a power 
of acting on their contents, independently of any force exerted on 
them by the heart ; and, further, that tliis power of acting on their 
contents was of two kinds, — the one in virtue of an elasticity, and 
the other by means of a vital contraction, similar to that possessed 
by muscular structures ; and this by a kind of evidence which, 
though, when rigidly considered, is scarcely so conclusive as some 
others derivable from natural phenomena, was still one to which 
the n^inds of men are nsually more accessible ; whilst it confirmed, 
or at least supported, conclusions drawn from those last-mentioned 
sources. In regard to Mr. Hunter, I allude chiefly here to his ex- 
periment of bleeding the horse to death, and then measuring the 
arteries, as already described. 

In explaining some of the most remarkable phenomena of the 
blood in the living body, it is essential to remember that the ar- 
teries possess this power ; for, as the heart impels the blood into all 
the arteries of the body, it is impossible that it can favour any par- 
ticular set of vessels ; so that, unless the vessels possessed a power 
of acting on their contents, it would be impossible to understand 
how it happens that one part becomes more loaded than another, 
or how it becomes nearly or quite deprived of blood : both of 
which occurrences are exceedingly familiar ; and as one example of 
the former is presented in inflammation, so Mr. Hunter's experi- 
ments had a direct connection with this process. To prove that 
the vessels of the inflamed part were enlarged, Mr. Hunter induced 
inflammation in a rabbit's ear, and afterwards killed the rabbit, 
and injected the arteries of both ears. He found that the ves- 
sels in the inflamed ear were larger than in the ear in which no 
inflammation had been induced. Then Mr. Hunter made experi- 
ments to ascertain the increase of heat in inflamed parts. He 
induced inflammation by acrid applications in differents parts of ani- 
mals, taking (both before and after the production of inflammation) 
the heat by the thermometer. The result was, generally, that in- 
flammation increased the temperature of the part, but scarcely 



261 



above that at the sources of the circulation, — viz. the chest of the 
animal. But Mr. Hunter thought (and verj naturally perhaps) 
that when inflammation took place near the sources of circulation, 
then the heat there also might become raised above the natural 
standard. Now no man can be less inclined to undervalue any- 
thing which Mr. Hunter has done, than myself ; yet a desire for a 
true and simple mode of study obliges me to remark, that the facts 
developed by these investigations, — and I allude especially to the 
increased quantity of blood in an inflamed part, and the increased 
size of its vessels, — are surely matters not more fully proved by 
Mr. Hunter's experiments, than they are by observation of inflam- 
mation as it occurs without its production by experiment. As one 
example of a thousand that might be cited, do we not notice, in an 
inflamed eye, for example, the vessels enlarge, as I have already 
observed; many carrying red blood, which before carried fluids, to 
us invisible ? 

A vast number of experiments have also been made with a 
view to determine the particular condition of the part inflamed ; 
and it would seem that the blood is accelerated in the large vessels, 
and that it moves more slowly in the small ones. 

Perhaps, as it would occupy your time very inexpediently to 
give anything like a digest of what has been done on this subject, 
I may tell you a few of the principal circumstances ; and I cannot 
do this better than by referring to a paper in the 4th volume of 
the Repertoire d'xAnatomie, by M. Kaltenbrimner ; because pheno- 
mena, which he asserts that he has seen, really appear very likely 
to occur in inflammation ; and his statement, as being the best and 
most probable account of what really happens in an inflamed part, 
will enable me, in a way most favourable for this kind of investi- 
gation, to contrast it with that which I hold to be the philosophical 
mode in which this important matter should be studied, and which, 
you will find, is not by concentrating our attention on the inflamed 
part. 

M. Kaltenbrimner says, that, after an injury to a part, there is 
a period, of longer or shorter duration, during which no phenomena 
are observable : and this he calls the period of incubation. Then 
inflammation begins : — 1st, there is a determination or flow (afflux) 
of blood to the part ; the circulation, also, is accelerated in the 
neighbourhood of the injury ; and that this extends to a circum- 
lerence, greater or less, as the case may be : after a time, the cir- 
culation in some of the vessels begins to be slow ; and at length the 



262 



blood in particular parts stagnates, forming " stases/' as he calls them. 
The process is now seen to be again stationary : after this, he sajs 
the congestion diminishes from the circumference to the centre ; and 
that the inflammation terminates by what he calls a true crisis, this 
being an exudation of a sanguineous fluid, " fluide sanguinolente/' 
He says that the points where the blood becomes stationary, form 
in the following manner : — at first the blood begins to move slowly 
in some of the capillary (minute) vessels ; and that then its move- 
ments become uncertain, and as it were vibratory, " le sang semble 
occiller irregulierement dans ces endroits;" and then, in different 
points, the blood stops altogether. That these " stases" form near 
the focus or centre of the inflammation, become most numerous as 
the inflammation is more violent ; that they form more quickly in 
some parts of the body than in others ; as in the spleen, liver, 
mucous membrane of the bowels, more quickly than they do in 
the lungs or mesentery ; and that the minute veins, and not the 
arteries, seem the situation of their commencement, &c. More- 
over, he says that they do not occupy the whole of the vessels, but 
that a void is left around them. 

He says, that, before these stagnations take place, the globules 
of the blood pass enlarged from the arteries to the veins; that 
some of these globules are evidently first decomposed by a separa- 
tion of the serum ; and that then several of them unite and become 
stationary, forming the "stasis" of which he speaks. This may 
be seen, he says, in the mesentery of a rabbit very distinctly. 
He adds that, in congestion, there are no stases; so that these 
seem to be one circumstance essential to inflammation. In suppu- 
ration, he says that the first thing that happens is the detach- 
ment of little flakes from the stagnations or " stases" which I 
have mentioned ; that several of these unite to form conglomerate 
clots (grumeaux agglomerees) ; these again uniting, form bodies of 
indefinite shape ; that now canals are formed round them in the 
surrounding parenchyma, which is thus gradually removed ; the 
canals, increasing, tend towards the surface, where they pour out 
their contents ; that, in sphacelus and gangrene, the conglomerate 
clots are not formed, but the flakes increase and move about irre- 
gularly, and ultimately destroy the parenchyma ; that, in gangrene, 
no motion of these flakes is observable. 

He says that the real termination of inflammation is by a 
secretion that exudes through the vessels, and that then the pus 
diminishes ; still the secretion that so exudes is very easily organ- 



203 



ized ; and that he has seen a net-work of vesssels form m it in the 
mesentery of a rat. The effects of inflammation often remain ; 
but this is the termination of the process. Farther, the various 
phenomena of inflammation described disappear in the inverse 
order of their occurrence, the kist disappearing first," and so on. 
Of the effects or traces of inflammation, he sajs that the vessels 
often remain too large for their contents ; that the fluid exuded is 
often absorbed; and that this is expedited by friction, stimuli, &c. ; 
but care must be taken in adjusting these, or inflammation may be 
reproduced. 

Some remarks, not uninteresting, follow in the relations which 
inflammation has to fever, &c, ; but the chief points are those I 
have mentioned as relating to the actual nature of what occurs in 
the part ; but you will see how very few of the occurrences are 
really of importance when we subtract from them that which a 
careful observance of the obvious phenomena supplies ; and, for 
the sake of disencumbering the argument, I will, for the moment, 
admit, that, notwithstanding most of the experiments appear to 
have been made on animals whose laws of life are so different 
from those of the human subject — as frogs, or animals writhing 
under suffering — I say I will admit, for the moment, that there are 
no objections to the conclusions so obtained ; that phenomena thus 
observed may be really those which occur in the inflammation we 
have to treat in the living body. 

Now the really essential facts for us to know^ — I mean as re- 
gards the seat of inflammation — may be stated as follows : 

That inflammation disturbs or suspends the function of the 
part attacked ; that an essential condition is, that more blood is sent 
to that part ; that, in proportion to its vehemence, it will, eceteris 
paribus, produce thickening, eflusion, suppuration, adhesion, spha- 
celus, or mortification ; that it has a great tendency to spread in 
some parts more than others, especially in serous membranes; that, 
as it absorbs or suspends functions, so is it most dangerous, as the 
organ performs a duty most indispensable to the animal oeconomy ; 
that, as an essential- feature of inflammation is a determination of 
blood to the part, and activity of its vessels, so the main object, as 
regards the part, is to diminish the action of the one and the quan- 
tity of the other*. But I would ask, which of these facts can we 



* The reader must not infer that I mean by bleeding. — See Treatment. 



264 



not safely deduce from tlie contemplation of the most common, 
everj-day, too frequent, and too unec^uivocal phenomena ? 

The truth is, that these facts emphatically establish that kind 
of treatment which we have hitherto been taught to regard as best 
for inflammation ; and neither M. Kaltenbrunner's facts, nor indeed 
Mr. Hunter's, do more : but that these are usually regarded as the ' 
essential facts, in respect to the treatment, is demonstrable ; because 
the present best-recognized treatment of inflammation is founded 
on them ; and the mere enumeration of the different points of that 
treatment will be sufficient to demonstrate the fact. 

We bleed, we stop the supplies of food, we endeavour to in- 
duce action of the various secretions, we give rest and remedies 
which experience has shewn to have a direct tendency to abate 
the action of the heart and arteries. Our remedies, to be sure, 
are not strictly confined to these measures, as I shall presently 
observe ; but they are those on which we are taught to place most 
reliance. 

It may be true, that this is the best treatment at present in use ; 
but that it is not the best treatment absolutely — that it is often un- 
successful, and where successful often injurious, and that therefore 
there must be some better treatment, notwithstanding whatever our 
ignorance of it may be — I hope to render sufficiently manifest. I 
would, however, observe, that the demonstration of one mode 
of treatment being imperfect, must not be held as necessa- 
rily involving the discovery of improved principles of practice 
(though I hope to shew this also) ; but still it is very important, 
as directing our attention to other more promising paths of en- 
quiry, inasmuch as, amongst many that are wrong, we at least, 
in perceiving any of these, increase the chance of hitting on the 
one which is right. 

Now, if the question were, why or how an inflamed part be- 
came red, how it became swollen, how it increased in bulk, why 
it throbbed, or why painful ? the probability is, that the remarks 
already made have led us to a sufficiently satisfactory explanation 
of the phenomena ; for, though the phenomena appear different, 
yet they are after all but a very common and almost universal con- 
sequence of increased action of the vessels, this condition neces- 
sarily implying more blood than usual. Pain is an increase of 
sensation, which, quoad the nerves, is as much increased action as 
\'io]ent throbbing is increased action of the arteries. 



265 



Pain is a verj natural consequence of obvious departure from 
the natural condition of a part. If bodily comfort result, as it 
undoubtedly does, from a certain harmony between the nerves 
and the impressions to which they are necessarily and ordinarily 
subjected, it follows that any departure from this must be produc- 
tive of the absence of such comfort ; and, accordingly, we either 
find that a negative condition, chiefly characterized by the absence 
of our usual comfort, is the result of small deviations from natural 
sensation ; or that, if this distance be increased, we either experi- 
ence pain on the one hand, or absence of all feeling on the other ; 
but we do not regard the beauty of this arrangement in the fore- 
going simple view of the facts : a very admirable result comes 
out of it, and highly calculated for the preservation of the body. 
When a disease occurs in a part, we should, a priori, be prepared 
to expect that parts usually most highly sensitive were attended 
by the greatest suffering ; but this is far from being the case. 
Neither would the use of pain be so apparent, either as a suggestion 
or a caution, or admonition, in structures already endowed with so 
vigilant a sensibility. We find the arrangement, however, made, or 
what appears to be more useful and apparently more intelligible 
laws ; for the result of pain being a state proportionate to the dis- 
tance from the ordinary condition of parts, it happens that struc- 
tures, ordinarily least sensitive, become the most so under disease. 
We see striking examples of this in bones, the whole apparatus of 
joints, ligaments, tendons, fasciae, and serous membranes. Hence 
the admonitions which pain conveys are in the highest degree 
salutary. We may judge of this by what would happen were it 
otherwise. Supposing that we were constituted the same as at pre- 
sent : when serous membranes were affected, disease would make 
rapid and dangerous progress before we were scarcely aware of its 
occurrence ; and, as tendinous parts, fasciae, and bony structures, are 
exceedingly apt to perish under excitement, we should have morti- 
fication as the ordinary, nay unavoidable, result of inflammation, 
and destruction of life or motion, but generally of both, when 
joints become the subject of disease. 

Thus, in these parts, the early, nay almost immediate, occur- 
rence of severe pain obliges us to adopt measures which, whether 
singly or in combination with other modes of treatment, are most 
eminently calculated to restrict the excitement to the living powers 
of the part. If joints, for example, are affected, repose — of all 



266 



others the essential remedy — is emphaticallj the remedy of Nature ; 
and in serous membranes the same thing is observable. 

If the abdomen be inflamed, yon have no occasion to tell a 
man to avoid exciting the alimentary canal, which it also invests, 
or to breathe gently, that the opposing surfaces may be as little 
moved as possible : nor have you any occasion for prescribing 
similar conditions in the chest. In both, the breathing is as short 
as possible, because the contrary is painful ; and loss of appetite 
and pertinacious rejection of all food secmes the alimentary canal 
from becoming the source of additional excitement. 

We may further impress the use of pain from instances in 
which it does not occur. Now there are diseases in which we see 
this, as scrofula ; and the very insidious nature of this disease — a 
material element in its destructive character — arises fromx the very 
general absence of suffering. From this cause many cases are 
allowed to make a very untoward progress before the proper means 
for their relief are adopted. The gums are an interesting example 
of a structure which is highly vascular without being sensitive, and 
of the diseased increase which may occur in such parts w^ithout 
exciting attention ; but they are parts the affections of which are 
of far less consequence to the oeconomy. 

To return, however, to the other characteristics : the expla- 
nation of all these occurrences, the ratio symptomatum, as it 
has been called (and which, as regards the actual state of vessels of 
the part, w^hether the larger arteries or their capillary termma- 
tions, has occupied the chief labour, if it have not engrossed 
the whole attention, of most enquirers), is, after all, not the real 
desideratum. 

What we really want to know^ is, why the phenomena occur at 
all, why the whole process is set up ; not w^hy or how- this or that 
feature of it may be explained. This is the real desideratum; and 
that the w-hole defect of our treatment results from this, is very de- 
monstrable ; as it will also, I trust, be evident that the information 
is not to be found in the part. But, if we are not to confine our 
view to the part on one hand, there is no reason why we should 
altogether disregard it on the other : the right thing is, to include it 
in our consideration, and adjust its value, not to reject it altogether; 
for Nature never gives us any demonstration which may not be 
turned to some useful purpose. 

In considering this subject, the very first thing that occurs to us 



267 



is, that by far the greater number of the more dangerous sorts of 
inflammation occur iu parts altogether out of view ; so that even 
were the h)cal phenomena, in visible inflammation, of that conse- 
quence that man J attribute to them, they would be of very little 
use in practice. 

Inflammation of the brain, the viscera, the membranes which in- 
vest them, often also of veins and fasciae, occurs without any evidence 
of the local character so much talked of as forming the essence of 
inflammation. But still it does not follow that diseases of the sur- 
face should not be consulted advantageously as types of Nature's 
mode of proceeding, in cases where the part cannot be seen. On 
the contrary, it is in this way that the study of surgery proves so 
useful, and, in my opinion, so essential, to the physician : but then 
it is quite obvious that we should study local manifestations with 
due care and attention, and, above all things, endeavour to sepa- 
rate those circumstances which are essential from those which are 
accidental or adventitious. 

Now, as far as I know, this has not been done in inflammation, 
nor indeed much in other local diseases. We consider inflamma- 
mation, nay we define it to be the coexisting occurrence of heat, 
redness, pain, throbbing, &c. in the part ; and yet, if viewed pro- 
perly, it is quite clear that all these are adventitious phenomena : 
they are very intelligible superinductions on inflammatory processes ; 
but not one of them can be regarded as essential. We there- , 
fore see at once how little possible it is that such a mode of viewing 
the matter should ever lead us beyond our present treatment. 

Redness often takes place in every part of the body without 
inflammation ; and inflammation may occur, and always com- 
mences, in some parts without redness, as in the cornea of the eye, 
and iris ; yet we can certainly quote no inflammation more insi- 
dious or more destructive of function than these. 

If such views of so common a process be entertained, no won- 
der that surgeons thus taught require separate instructions with 
regard to this particular organ. Irieat and redness of parts are also 
exceedingly common without any inflammation. Blushing and re- 
action after cold are examples of both : whilst we have no op- 
portunity of knowing the temperature in the most important 
inflammations which we have to treat. 

It is certain that many inflammations, even near the surface of 
the body, dubious in their progress, but not distinguishable from 
inflammation as to their results, afford little evidence of increase of 



268 



temperature. Throbbing is also by no means an essential symptom 
of inflammation. In the first place, in many slow inflammations 
it is wholly absent ; but, what is also to the purpose, throbbing 
especially, to a violent degree, takes place in the head, for example, 
without any inflammation. In short, to a certain amount of local 
excitement of the arteries, throbbing is doubtless essential ; but local 
excitement of the arteries, though essential perhaps to inflamma- 
tion, yet inflammation is not essential to it ; for the simple reason, 
that throbbing often takes place without it. 

But, when we consider swelling, we have more difficulty in 
separating this from inflammatory processes ; for we very rarely, if 
ever, see inflammation without increase of bulk, and scarcely ever 
increase of bulk without accompanying processes, which, although 
they may not readily range themselves under our ordinary notions 
of inflammation, it will be found, as we proceed, impossible to dis- 
connect from that process ; since the essential characters, the re- 
sults, the laws of animal oeconony, to which they refer, will be 
found to be similar, if not identical in both cases. We know of no 
inflammation without some secretion ; w^e know, nor can we con- 
ceive any secretion without an increased action in vessels of some 
sort or other, and, therefore, inasmuch as we cannot separate the 
phenomena of inflammation from increased action of vessels of 
some sort or other, we at length narrow the local question into 
this, to what order of vessels are we to refer this increased action ? 
and the answer to this appears to me to be, primarily the arteries, 
and subsequently the whole vascular tissue ; more blood is sent to 
the part, more is returned ; both arteries and veins are larger, more 
is secreted. 

On the same evidence, we see that the equilibrium of secretion 
and absorption is disturbed ; and that, whatever the absolute 
amount of absorption may be, we see that there is more deposited 
than taken away ; otherwise no increase of bulk, of course, could 
take place. But, w^e now come to the really important question- — 
why does inflammation occur at all? and this is as diflicult, 
perhaps, as important ; but, let us see then whether the simple cir- 
cumspection, on all the phenomena, which are so bountifully show- 
ered on us, and so intrusively invite our observation, will not do 
something to solve this difficult, because as I believe neglected, 
problem. 

The few foregoing remarks afford you little idea of the vast 
quantity of labour which has been uselessly expended, in en- 



269 



deavoiiring to unfold tlie proximate cause of inflammation, that is, 
what is the particular or precise state of the vessels of the part ; but 
we see the unprofitable nature of the conclusions to which this 
labour has led, in that the onlj useful facts are those which may 
be really obtained with scarcely more labour than common atten- 
tion to obvious phenomena. 

It is, for example, evident, in most visible inflammations, that there 
is increased heat, bulk, with redness and pain ; and whether we adopt 
this or that explanation which has been oifered of the immediate 
cause of these phenomena, or reject them all, it is clear that we 
found our present treatment on that which, in visible inflammations, 
is the most obvious and constant, and of which the explanation is 
most glaring and conclusive. I mean redness, which is one evi- 
dence of an unusual quantity of blood in a part, of increased activity 
in its vessels, or of both ; but you have seen that redness is itself 
an adventitious circumstance consequent on the colour of the blood, 
as is also the evidence thus afforded of the activity of the vessels. 

That the leading feature in the present mode of treatment is 
deduced from this evidence of more blood in the part is plain, 
from bleeding being of such general adoption ; for, however modi- 
fied the abstraction of blood in various cases, still the essence of 
the treatment is a subduction of vascular action by depletion, and 
this equally where bleeding forms part of the treatment as where 
it is omitted. The consideration of purging, sweating, counter- 
irritation, or depressing remedies, ultimately resolves them into 
means calculated to diminish the vascular action in the part. The 
treatment, in fact, entirely consists in ministering to the symptoms ; 
it does not, so far as I see, embrace any enquiry even into the 
causes whence it may really have arisen. If the case be mild in 
degree, or in a part which is unimportant, the treatment is directed 
to the part to diminish the quantity of blood circulating there ; but 
if the inflammation be violent, or the part important, why then we 
diminish the actions of the whole system, to diminish the actions in 
the part ; as if, not being able to guide the system aright, we had 
no other means left but stopping its actions altogether, so far at 
least as was consistent with the preservation of vitality. 

Now, were the treatment thus briefly adverted to uniformly 
successful, or could we even satisfactorily explain the reasons of its 
frequent failure, we might excuse our ignorance of this subject, and 
regard our knowledge, small though it be, as having already reached 
that limit allowed to our finite capacities. But no man of reflec- 



270 



tion can seriously entertain this idea for a moment. A very few 
facts, intrusively thrust on our notice, as it were, show not only the 
puny condition of our knowledge, but that the way is open for its 
growth and improvement. We see, in fact, that, however it may 
happen, our present treatment may remove inflammation; yet 
it is quite evident that the treatment and the cure do not stand in 
the relation of cause and effect. For example, many of those 
cases which terminate unfavourably, are those in which we have 
had the fullest opportunity of carrying out the whole of our treat- 
ment in its most pow^erful and energetic manner. I have seen a 
patient die of inflammation, where the direct depletion was carried 
to such an extent, that some thought that the patient died of the 
depletion ; yet, when the peritonaeum was examined, it was found 
to be highly inflamed, and regarded, and probably with justice, as 
the cause of death. 

I have also seen an eye perish by suppuration consequent on 
what would be called a pure inflammation, notwithstanding the 
adoption of the most vigorous anti-inflammatory treatment. The 
inflammation, commencing in the conjunctiva, rapidly extended to 
the globe, and, as I have said, the eye was destroyed by suppura- 
tion. I grant that, when not accompanied by morbid complications, 
which we have already learnt to recognize, such occurrences are 
rare ; but that renders them the more valuable when they do occur ; 
and it thence becomes the more important that we should not 
neglect the lesson they teach ; for no natural phenomena, of any 
kind, are ever less than the exemplification of important laws : our 
ignorance is the only bar to the discovery ; and this arises, in ninety- 
nine cases out of a hundred, for want of observation, in the philo- 
sophical sense of the word ; they must be seen by the mind's eye as 
well as the body's. 

But if inflammation does occasionally prove fatal in spite of 
the most severe lowering and depletory treatment, — and if this be, 
as it undoubtedly may be, regarded as an exception to the ordinary 
result of such cases, — still it is by no means the only circumstance 
which occurs in the history of inflammation which seems to throw 
a doubt over the depleting plan being the real remedy for the 
disease. For the converse of what I have just stated is also ob- 
served : I mean that, occasionally, inflammations^ apparently pure 
as we call them, do well without the abstraction of blood, or indeed 
without any means which can })e reasonably explained on the 
principle of depletion ; and cases occur wherein, although bleed- 



271 



ing has been largely employed and the cases do well, still the 
history renders it extremely doubtful whether the bleeding were 
the cause of the recovery. The cases to which I allude are un- 
frequent, it is true ; but they are sufficiently common to be familiar : 
they consist, first, of cases wherein patients have refused to be bled ; 
secondly, cases where depletion has been entirely neglected, or but 
sparingly practised, on account of some contra-indicatiou, as debility; 
thirdly, of cases where bleeding has been carried both locally and 
generally to as great an extent as the medical attendant has dared 
to employ it, without materially influencing the symptoms, and yet 
the case may have recovered. Many years ago I was much struck 
by the following facts, which I remarked with the view of making 
them the subject of reflection, when the attention to the various 
details of an arduous profession should give me breathing time for 
the purpose. I knew a gentleman in very extensive practice ; his 
peculiar opportunities, both public and private, led him to see 
a larger number of patients than, perhaps, any other man in 
London ; moreover, he was a steady, skilful, and what is more to 
our present purpose, a very successful operator. 

It is interesting to remark too that he performed a great number 
of operations for hernia ; and so successful was he, that, out of about 
sixty-five operations for strangulated hernia, it is reported, he 
hardly lost two patients. He was a man who thought very much 
for himself too on all subjects, and was in many points very pecu- 
liar in his notions ; and what, know^ing the general truth of the fore- 
going remarks from the best authority, impressed me strongly as a 
curious fact, was, that he hardlj' ever bled at all in inflammation ; 
nor was this fact the less interesting to me, from knowing that he 
w^as very active in his other measures, particularly purgatives and 
blisters. I am far from inferring, from these facts, that we should 
avoid blood-letting in the present state of our knowledge ; I wish par- 
ticularly to guard myself from conveying such an impression, which 
will be further explained w-hen I treat expressly of that remedy ; 
but the facts, whilst they throw a very strong doubt over our pre- 
sent practice being otherwise than exceedingly imperfect, teach us 
to look farther a-field, as I would say, in a manner which I shall 
explain as I proceed. Another class of facts, which must be borne 
in mind, are those which show^ that neither heat, pain, redness, nor 
even perceptible sweWmgy Sire essential characters of inflammation ; 
because in inflammation either of them may be absent ; and, on the 
contrary, either of them may be present without inflammation; just 



272 



as intolerance of light is an usual sjmptom of inflammation of the 
eve : yet inflammation may exist without intolerance of light, or 
intolerance of hght may exist without inflammation, — a very 
common circumstance in strumous children. 

It appears to me, that, if ever we are to progress in our know- 
ledge of inflammation, and consequently in improving our treatment 
of it, — if ever we are to be able to refer it to laws, of which it must 
doubtless be the exemplification, — we must enquire into its real, and 
that this will be by understanding what is now technically regarded 
as its remote, cause. Instead of enquiring, in fact, what is the con- 
dition of the vessels, or any other structure of the part inflamed, 
we must grapple with the question why inflammation occurs at all ? 
and I cannot help thinking, that, however various the apparent or 
exciting causes of inflammation may be, or however multiplied its 
appearances, its complications, or its efi^ects, they are all referrible 
to one law in the animal oeconomy. 

There is nothing unphilosophical in this supposition, or contrary 
to the general experience afforded by the contemplation of the laws 
of nature; since any law with which we are already acquainted, — 
such as gravitation, or those regulating the motion or pressure of 
fluids or aeriform bodies, for example, — range under their dominion 
phenomena, to say the least of them, just as A^aried, quite as nume- 
rous, quite as much out of the reach of guess or anticipation, as 
would the phenomena of inflammation be, even were their number 
greatly multiplied. 

I fear that the medical reader will think that I have dismissed the 
subject of the proximate cause of inflammation in too summary a 
manner. The truth is, I regard the enquiry as one on which more 
valuable time has been wasted than on any other subject whatever; 
and we have business in hand which is more important. I will 
therefore refer the reader to a sentiment of Lord Bacon's, quoted 
in the First Discourse*, and proceed to consider the real causes of 
inflammatory action. 



* Page 26. 



273 



DISCOURSE VIII. 

ON THE REAL CAUSES OF INFLAMMATION. 

In approaching this difficult subject, it seems prudent to adopt 
that plan which is found in other departments of knowledge where 
advances have been more considerable than those of medical science. 
Now, wherever a law of extensive influence is discovered, an at- 
tempt is usually made to discover what other phenomena, in addi- 
tion to those already so disposed of, can be referred to its operation. 
In this way the enquiry is often proceeded in very advantageously, 
by asking questions of Nature, as it were, under the suggestions of 
that law. For, as progressing science seems to be constantly tend- 
ing to diminish the number of laws, in relation to the number of 
phenomena, by ranging an increasing variety of the latter under 
laws already discovered ; so we are always led to infer, a priori, 
when we find a certain law in operation, that it comprehends more 
phenomena than our present knowledge enables us to ascribe to it. 
Now, if we look at the oeconomy of the human body, there seems, 
in relation to its preservative processes, or to its diseases (which, 
properly understood, are really nothing but attempts at such pre- 
servation), to be nothing so like a law, or more tenably establish- 
able as such, than the tendency of certain actions, which we call 
diseases, to the surface of the body. But in examining any law by 
means of its phenomena, our perception is very materially in- 
fluenced by the order in which we examine them. 

They form a continuous chain in all cases ; but the connexion 
can be traced only by examining the links in the order of their 
proximity. If v/e do this, the connexion is palpable and easy ; but 
if we jump from one link to another remote from it, the continued 
type, plan, or principle, may be just as true, but so modified as to 
escape detection. I'his is well known to comparative anatomists ; 
but I beg you to think of it as vastly important in connexion with 
the study of diseases. 

If we examine the manner in which injurious agents are got 
rid of in health, we find that they are brought to the surface ; in 

T 



274 



other words, they are ejected from the body. Many organs seem 
to have this as their chief, if not their only function ; such as the 
kidney, the large intestines, and perhaps the skin : and, again, other 
organs, whose primary or chief function may be of another kind, seem, 
nevertheless, to contribute in part to the ejection of injurious influ- 
ences, as the lungs and liver. We draw these conclusions from those 
facts which shew that, if any of these functions become suspended, 
the oeconomy at large becomes exceedingly disturbed ; and from ob- 
serving that even any irregularity or embarrassment in these func- 
tions, either also disturbs the oeconomy, or requires an extra, and 
indeed a compensating, exertion from some other organ. Besides 
this, we know that many substances are thrown off, which would 
be positively injurious ; such as carbon from the lungs and skin, 
and the peculiar matter which constitutes the urine. 

That the action of the bowels cannot be suspended or embar- 
rassed with impunity, unless some compensating influence be sub- 
stituted, is too well known to require anj^ amplification. We also 
know, that when all these organs become simultaneously embar- 
rassed, the system becomes peculiarly excited ; that there is then 
disturbed respiration ; paucity of secretion from bowels, skin, and 
kidney, and frequently liver also ; with excitement of the heart 
and arteries ; which constitute, in fact, what is called fever. We 
know, further, that a very common relief from this state, is a deter- 
mination of secretion to some one of these organs ; and, perhaps, 
none is more frequent or more etfectaal, than to that which forms 
the surface of the body. But of this we feel certain, that this de- 
termination must be evinced by some one of them ; because a 
patient with fever was never perhaps known to recover without it. 

In order to be clear, this determination may not, it is true, be 
evinced by an increase of any of these ordinary secretions, or by 
any superaddition to them ; but then we have what we call inflam- 
mation, and then the most safe is that which occurs on the surface : 
the recognition of this fact is popularly expressed, by saying, that 
the fever has fallen into such or such a part. And if, in such 
cases, we begin to bleed and use debilitating influences, we often 
risk the life of the patient, of which I have seen a most marked 
example ; but of this hereafter. It is true, also, that, in the ab- 
sence of this, we may have inflammation of some internal part, 
which is highly dangerous, and the reason of which I shall en- 
deavour to explain in its due place. 

We accustom ourselves to make certain diflerences in regard 



275 



to subjects which are matters of sense, which we can see, handle, 
and touch; and those to which we can apply neither of these 
modes of recognition ; and some of these differences, as giving 
that precision to language which is necessary for the communi- 
cation of the several characters attached to such matters, are of 
course necessary. Such are those differences which refer them to 
their obvious qualities, — as colour, form, hardness, softness, &c. 
When, however, we extend our notions to the laws which regulate 
the phenomena exhibited in visible and tangible matters, and con- 
ceive that they must be essentially different from those which 
regulate invisible or intangible forces, we do two things, equally 
unsafe and gratuitous. Gratuitous, because we have no facts on 
which we can legitimately ground such distinctions ; and unsafe, 
because the assumption supposes powers of distinction in our ex- 
ternal seDses, which they do not evidently confer on us. I must 
beg you to consider this, in all endeavours to interpret the phe- 
nomena of Nature. 

When we set about collecting phenomena or facts in regard to 
the living body, and especially when we have collected a vast 
number (for, however poor medical knowledge may be, regarded as 
a science, it is fortunately rich in facts) and proceed to throw them 
into some kind of arrangement, with a view to ascertain their 
natural relations and dependencies, we are struck by the large num' 
ber wliich obviously possess one character in common ; and this 
regards the situation in which they occur, or in which they ulti- 
mately terminate, — this being the surface of the body. Knowing 
that everything in Nature is regulated by some law or other, we 
know that these facts must be so regulated ; and, from their occur- 
rence in the same machine, or the same being, we naturally infer 
that the law which regulates them is, in all probability, one and 
the same. We must first, then, collect the facts ; and, having as- 
certained any one property they have in common, we must extend 
our enquiry with a view to ascertain if they have any other pro- 
perties in common ; because the accumulation of such common 
properties will afford us only the true help in ascertaining, either 
the law under which they occur in common, or the proximate agent 
in the administration, as I may term it, of the law. 

In teaching, and especially in conducting the enquiry I am now 
about to unfold, we must suppose nothing ; we must first collect 
facts. I have already mentioned how certain things, no matter of 
w^hat kind, whether tangible or intangible, are thrown off from 



276 



the body by the lungs, liver, skin, kidney, and so on ; the reasons, 
whence it is evident that something injurious is thus thrown off, 
consisting in the manifest disturbances which follow its retention, 
and being farther illustrated by the mere glance which we have 
just given, for the present, at the phenomena of fever. 

We will now, then, proceed. We find that, under various cir- 
cumstances, foreign bodies, as bullets, stones, pins, needles, thorns, 
&c. are made to enter the body ; that sometimes, as a direct con- 
sequence of the force with which they impinge on the body, as 
bullets, and sometimes from other causes, they travel very curious 
routes ; these leading them to considerable, and even indefinite 
distances from the part at which they entered the machine. But 
we find, whatever the com-se of such foreign bodies may be, that 
they ultimately are brought (with very few exceptions) to the sur- 
face of the body. Pins and needles have been even swallowed, 
and yet have been safely conducted to the surface, and there ex- 
pelled. I recollect a patient who sat down on a needle, which 
entered the part, and was for a time lost sight of : at length, a little 
spot of inflammation was set up on the outside of the knee of the 
same side, and this ending in a tiny abscess, the needle was dis- 
charged. Such examples are familiar to surgeons. Mr. Hunter 
mentions them, and states the mode of their progress, in saying 
that the route is made for the foreign body by the absorption of 
parts. He adds the term progressive, but perhaps that is not ne- 
cessary ; the statement of the simple flict is sufficient. 

It is trae, that this ejection at the surface does not happen ab- 
solutely without exception. Foreign bodies are sometimes retained 
in the body, of which gun-shot wounds present occasional ex- 
amples : yet it would seem that even then they are in a manner 
isolated from the body. I recollect once examining a body with 
Mr. Stanley, in which we found a bullet on the inside of the ster- 
num (breast bone) ; it was adherent there, but it was wrapped up in 
a neat little capsule or bag, which Nature had formed around it, — a 
fact which I shall make use of by and by, in regard to, apparentlijy 
a very different matter. 

Another fact, mentioned by Mr. Hunter, which I wish you to 
consider, is the progress of an abscess. Matter forms, we will say, 
on the abdomen, deep away from the skin, and very close to the 
abdominal cavity. A thin membrane may only intervene between 
the abdomen and the matter ; whilst muscles, fasciae, cellular tissue, 
and skin, constituting a great thickness of parts, are interposed be- 



277 



tween the matter and the surface. Notwithstanding, the matter 
comes to the surface, a road is made by absorption, either through 
or between these various structures, and the skin becoming thin, 
and absorbed at a certain point, the matter is discharged at the 
surface. Now this is very curious, and it is equally true, if I had 
supposed the abscess to have taken place in any other district of 
the body ; and we shall find it to happen in a hundred, or even in 
a thousand instances, before we find one example of the contrary. 
We can perceive no reason of a mechanical, nor from the isolated 
fact of any other kind, why the matter should not ha\-e made its 
way towards the abdomen ; since, in regard to apparent mechani- 
cal obstructions, there w^ere much less on that, than on the side 
next to the surface of the body. So, w^hen an abscess forms ac- 
tually within the cavity of the abdomen, or chest, the same thing 
is generally true ; nor is the bursting of an abscess, elsewhere si- 
tuated, into the alimentary canal, or into any of the ramifications of 
the respiratory tubes (both of which occasionally happen), to be 
hastily set down as an exception ; since this also involves, in fact, 
the expulsion of certain matters from the body. So, if an aneurism 
forms, we find that it makes its way to the surface, — bones, or all 
other structures, whatever their nature, becoming gradually ab- 
sorbed ; and, in the same degree, the aneurism approaching the 
surface, until at length, if nothing be done to remove the cause of 
the aneurism, or cut off the supply of blood to it, the skin itself, 
which forms its last covering, becomes removed. In a case wherein 
I tied the femoral artery for an aneurism of the ham, about three 
years before, an aneurism formed in the aorta, which, coming into 
contact with a portion of the alimentary canal, burst into it ; the 
patient dying, not at once, but by repeated haemorrhage. 

If we continue our observation of the surface of the body, we 
perceive a vast number of other phenomena of a similar character. 
You know that the efflorescence of scarlatina, the eruption of 
measles, or pustules of small-pox, all occur on the skin ; and you 
also know" that these complaints alone furnish thousands on thou- 
sands of examples of actions taking place, of some kind or other, — 
of what kind we shall examine presently. Still, even these form 
but a very few sources of the phenomena observable in this situa- 
tion. The various diseases of the skin furni'sli a multitude of other 
examples. In Dr. Bateman's Synopsis of Diseases of the Skin, 
alone, in which an arrangement is made of them from certain 
resemblances in their obvious appearances, there are mentioned 



278 



about 130 different forms of disease ; and yet this includes, cer- 
tainly, but a comparatively small number of those diversified 
forms which are seen in Nature. So that, in fact, we soon find 
that the catalogue of external actions, when we multiply their 
obvious varieties in appearance, by the number of persons affected 
in all countries, by one or other of them, is so great as to exceed 
all powers of calculation. 

But still, we have not done with examples ; for a great number 
is yet to be added from sources not included in the mention of 
those already referred to. We have gout, erysipelas, boils, car- 
buncles, common inflammation, and a multitude of diseases of the 
eye ; all of \vhich are common complaints, all of which affect a 
large number of people, and all of which occur at or near the 
surface of the body. 

All this is very remarkable ; and the first thing presented in the 
enquiry thus made, is, that we have observed an infinite number of 
phenomena, which have this one thing in common, — that they have 
all a certain seat, or a tenrlency thereto, this being the surface of 
the body. 

At this stage of the enquiry also, we gradually arrive at the 
perception of another relation which they have in common ; and this 
is, that the tendency of such actions is, in the main, beneficial to 
the animal oeconomy. In some, it is demonstrable ; in others, a 
matter only perceptible through some previous reasoning; in a 
third class, an inference of high probability ; but, in all, the general 
beneficial tendency is clear and intelligible. In the case of the 
foreign body, we see the oeconomy displaying so much of a bene- 
ficial tendency, that it discharges what at least we can be quite 
certain is of no use to it, — as a bullet, pins, needles, and so on. 
In measles, scarlatina, and small-pox, we infer benefit, because 
the eruption relieves the disturbance which preceded it ; and we 
observe, also, that the eruption is usitally in harmony, as to its 
degree, with the constitutional disturbance which it relieves, — that 
is, if the previous disturbance be great, so is the eruption, and 
vice versa. The repercussion, as it^is called, or the sudden dis- 
appearance of all diseases of the surface, is a circumstance highly 
dangerous to the animal oeconomy. This has been often exem- 
plified in various instances ; in most of what we call cutaneous 
diseases proper, and also in gout and many other disorders. One 
more example, which I mention on account of its incontestible fre- 
quency, is seen in the history of those multiform processes which 



279 



take place on the surface, — the variety of sore legs, ulcers of the 
extremities. Injurious consequences are well known frequently 
to follow the healing of such ulcers ; and it is equally certain, that 
these consequences are most common when the ulcers appear 
to heal exclusively in consequence of local applications ; and, on 
the contrary, that when their healing is accompanied by, or ac- 
complished through, means of improvement of the general health, 
it is safe. The connection between ulceration of the extremities, 
and general disorder, is still more strongly impressed, if that be 
possible, by those cases in which they are seen to occur in alterna- 
tion ; such as oppression of the chest when the leg is well, and 
free respiration when it is ulcerated, of which I have seen a mul- 
titude of examples ; nor can we connect that disturbance of the 
whole oeconomy, which is known to follow the sadden disappear- 
ance of disorder on the surface, with any particular form of dis- 
ease. We know it as an occurrence ; more familiar, it is true, in 
some forms of disease than in others ; and especially in those 
which are more glaringly marked by previous disturbance, or at 
least by the presence of injurious influences, — as gout, for example ; 
but still we can select no form of disease of the surface in which 
experience shall enable us to say, that its sudden disappearance 
may not be followed by some other disturbance of the general 
oeconom}'. More of such illustrations must be given as we pro- 
ceed ; so, for the moment, let these suffice. 

On comparing now the retrospect with the prospect, we not 
only perceive that diseased actions, which occur on the surface, 
are very numerous, but that they are more numerous than those 
which take place in any other part, and, in fact, than in all other 
parts put together. This is, indeed, a striking result, and one 
which impels us, with a renewed vigour, to further enquiry ; but 
let that enquiry be, first, the further collection of phenomena. Let 
us increase our facts. 

Having examined the skin, then, we follow^ its continuations, 
and we find them lining the canals of the body, the respiratory 
digestive and urinary organs, and forming what I have already told 
you are the mucous membranes. All these parts are continuous, 
you will recollect, with the external surface, exactly as the inside 
of a glass is continuous with its outside ; moreover, some of them 
are primarily employed (as the stomach and lungs) for the recep- 
tion of matters from without; in other instances, wholly in their ex- 
cretion, as the liver, lower bowels, and urinary organs ; the lungs 
discharging both offices. 



280 



In leaving the actual surface, we have declined investigating 
local injuries, as not being either necessary or strictly applicable 
to the argument. Now in the throat we meet with daily occur- 
rences of diseased action of some sort or other ; common colds and 
sore throats are familiar examples ; we find also, if we continue our 
search into the windpipe and its ramifications, that here again we 
meet with a crowd of disordered actions, of which daily instances 
are presented to us, so that we cannot walk the streets without 
meeting them. I mean irritation of the lining membrane of these 
tubes, and secretions of various kinds which take place from it. 

So in regard to the actions of the mucous surface of the ali- 
mentary canal. This has been already mentioned as always active. 
Of what we call disease, too, we observe continued and daily ex- 
amples. Sickness, purging, various augmentations, as well as innu- 
merable examples, of disorder of secretion, demonstrate how almost 
infinite are the disordered actions which go on in this structure. 
Then, at both its extremities, we have various affections of the 
mucous surface ; not that all those which we observe in this situa- 
tion are instances in point (which I mention to avoid conveying an 
impression which is not true). You know that diarrhoea, dysentery, 
cholera, all appear to be seated in the mucous membrane of the 
bowels, or to be disordering influences determined thereto as their 
ultimate destination. 

Then, if we examine into the apparatus bj' which the urinary 
secretion is discharged, and which also is in continuation with the 
surface of the body, we see actions so often occurring there, that, 
although the consequences to which they lead, from neglect or what 
not, often involve every other structure, yet they commence, almost 
without exception, in the mucous membrane. Now, when we 
have collected this, which I may call a second series of phenomena, 
and when we compare them with those collected from the surface, 
we observe some results highly interesting. We perceive two 
things which they have in common : first, that the actions in each 
terminate by ejecting something from the body ; and, secondly, 
that, a' though the processes vary in many of their features, they 
still involve, in many and in most instances, the common phe- 
nomena of inflammation, and in all, its essential character ; that is, 
increased or altered action, and increased or altered products : 
usually both. It is absolutely necessary that we should, in ex- 
amining the phenomena of inflammation, extend the idea to in- 
creased action ; and this, because in tracing that or any other 



281 



plienomeuoii, we must, as Lord Bacon says, " extend our investi- 
gation to things in common." Now, in all inflammations, however 
different, we have one thing in common (increased action) ; and, 
although increased action may not necessarily imply w^hat we term 
inflammation, yet it is, as I have said, not only the most universal 
attribute of inflammation, but it is its most essential feature. Per- 
haps congestion may be the proximate link to it ; secretion, simul- 
taneously with, or independently of, demonstrable congestion, the 
next. At all events, increased secretion is increased action ; and 
inflammation, though it may be different in kind, is essentially 
nothing else. 

There is one other surface which, although external, is not like 
the skin exactly, but is a mucous membrane ; and that is the con- 
junctiva, which lines the eyelids, and is reflected on the front of 
the globe of the eye. We know that this organ is affected by a 
vast number of diseases ; so that, by practising on the ignorance 
and credulity of the public, it has been represented to them as 
affording a separate family of diseases, as it were ; as if something 
peculiar existed in regard to them, or as if they were under differ- 
ent laws : and I would by no means assert, that oculists may not, 
in many cases, be their own dupes, in a scientific sense, and actually 
believe that it is so. However, I only mention all this to impress, 
first, that diseases of the eye are very numerous, as regards those 
appearances on which our nomenclature is founded ; and secondly, 
that, when we enquire where they occur, we find that, taking the 
whole mass of patients affected with all known disorders of the 
eye, the proportion of those on the surface to those in any other 
part of the organ is greater beyond all calculation. Common 
ophthalmia, catarrhal ophthalmia, scrofulous ophthalmia, purulent 
ophthalmia, in its various forms of degree and variety, erysipelatous 
ophthalmia, of which you see many examples in debilitated con- 
stitutions, all occur on the surface ; and, to give you some idea of 
how large, and in fact incalculable, proportion of diseases of the 
eye are seated in this membrane on the surface, I may observe, 
that, in regard to only one variety, namely, the scrofulous ophthal- 
mia. Beer says, that about ninety cases out of every hundred are 
cases of this form of the disease*. 

In connection with this form of ophthalmia, I beg you to ob- 



* Nor does the fact that climate is implicated in producing scrofula explain 
this circumstance. See this subject resumed further. 



282 



serve two thiugs : first, that, although we cannot say that it may 
not often be excited, or otherwise influenced, by local circum- 
stances, yet there is no ophthalmia, nor any other fonn of disease in 
the eye, that we can more constantly connect with derangement of 
the general health, nor any which is so nearly exclusively confined 
to the surface of the organ. All other inflammations, if not 
watched, may and do destroy the eye by the inflammation extend- 
ing to other structiu'es; whereas, when strumous inflammation 
injures the organ (and this it seldom does now, unless entirely 
neglected or negligently treated), it is almost invariably by a speck of 
opacity on its surface. Beyond this, it is very rare indeed to see 
strumous ophthalmia do any harm ; and when a speck occurs, it 
has always been, in my experience, consequent on an ulcer which 
existed before the patient was brought for treatment. I lately met 
with a case which interested me in respect to this subject, and 
which is worth relating. A little boy was brought to me with aii 
afi'ection of the eye, which, from the aspect and age of the child, 
and the intolerance of light, ^^ithout much appearance of inflam- 
mation, seemed a light form of strumous ophthalmia ; but, on look- 
ing into the eye, I perceived that the inflammation, though shght, 
was of a pinky colour, and e^-idently seated in the sclerotica. 
There was a small spot of ulceration on the cornea, with a minute 
vesicle on its point ; and, on examining it with a magmfler, I per- 
ceived a black spot on the vesicle. On enquiring whether the eye 
had met with any injury, the mother assured me that it had not ; 
which statement the boy confirmed. I then asked whether he had 
any pains in his limbs, or whether he had caught cold ; which en- 
quiries were answered in the negative. I now enquired into the 
nature of the boy's employment, and was told that he assisted in 
filing brass and iron. I then had Httle doubt that a portion of iron 
had flown into the eye and penetrated the cornea. I took a piece 
of fine linen, and passed it lightly over the ulcer ; and thus brought 
away a small particle of black substance — another portion, however, 
yet remaining. As the vesicle induced me to think that the cornea 
had been peneti'ated, and that nothing but the membrane which 
lines the anterior chamber remained entire, and as the boy seemed 
somewhat relieved, I used no farther measures to extract the 
remaining portion. The inflammation rapidly subsided, and the 
boy did very well. Had I been less scrupulous in my examination, 
I might possibly have regarded this as a case of stiimious ophthal- 
mia, primaiily affecting the sclerotica : since, curiously enough, the 



283 



bo J had a large, prominent eye, thick lips, and altogether the 
aspect of a strumous disposition. 

Now these remarks in regard to the tendency we observe in 
scrofulous ophthalmia to confine itself to the surface of the organ, 
under varying degrees of inflammatory excitement, do not apply, it 
is true, with the same force to those other numerous varieties of 
ophthalmic inflammation which I have mentioned ; but, as regards 
the seat which they primarily occupy, it is as true in respect to 
them as it is of the strumous species. Thus our enquiry hitherto 
seems to supply us with a still greater number of disturbances, 
which, if not all actually on the surface, yet are either so placed, 
or else on a part — mucous membranes, for example — which, in a 
practical sense, presents us with results analogous and (as regards 
the ultimate ejection of certain matters from the body) identical. 

In continuing our enquiry still farther, we however find other 
phenomena, other actions of the system, which seem, at first sight, 
to be exceptions to the general character presented in those we had 
already collected ; for we observe actions of disease, inflammatory 
actions in fact, occurring in various other situations ; so that, at 
last, we arrive at tbe fact that there is no structure in the body, nor 
any combination of structures, which may not be aff'ected by 
inflammatory action. Now, if we had a growing conviction that 
the remarkable tendency to the surface, which we had observed in 
such myriads of instances, had any relation to any law which 
determined the actions in question, we should be led to regard 
inflammation occupjing other seats in the light of an exception ; 
for the heart, brain, lungs, and liver, are unquestionably, in some 
cases, the seat of inflammation ; and, as such, they appear, prima 
facie, as "contrary instances" to that general ttiidency to the 
surface which we had hitherto observed as so striking. Now it is 
the essential part of an inductive philosophy, that these or any 
other exceptions to any law which we may propose to establish, be 
explained or accounted for ; otherwise we can by no means esta- 
blish such law. If we can explain the exceptions, then they are 
no longer such ; but more emphatically establish the law of which 
they appeared as aberrations If we can account for them by 
reference to certain interferences, and we can conduct this account 
to a high degree of probabihty, then the law may, though not de- 
monstrable, be still rendered highly probable ; but, if we can do 
neither— that is, neither account for nor explain the exceptions 
they form as apparent and not real — nor shew with probable cor- 



284 



rec'iiess the iufluences which interfere with their exhibition of the 
laws, we must suppose that thej have no relation to it. 

Now the examination on which we are about to enter appears 
to me, instead of increasing any doubt which we are bound to 
entertain, to convert it rapidly into conviction. 

To begin w^itli the brain. \Yitliout refining unnecessarily, we 
will admit that the brain becomes occasionally inflamed. We find 
the products of inflammation of the brain in the ventricles ; but 
then these are lined by a serous membrane, of which these cavities 
are, strictly speaking, on the outside. But cavities are found in the 
substance of the brain, undergoing various changes, as in certain 
cases of efiusion of blood from apoplexy. The blood becomes ab- 
sorbed, the cavity covered bj' a smooth surface, and ultimately 
filled by a fluid The brain also occasionally undergoes positive 
change of structure, of a solid form, in the deposition of scrofulous 
and other tumours. General fulness of the cerebral vessels, which 
is an essential element in inflammation, likewise occurs ; so that all 
these circumstances, w-hether regarded separately or in combina- 
tion, leave no doubt but that the brain is subject to inflammation. 
But we now find an important fact of another kind ; viz. that, for 
one case wherein this happens, perhaps a hundred, or perhaps a 
thousand, in fact an indefinite number, occm', in which the inflam- 
mation is either confined to the membranes of the brain, or has 
demonstrably commenced in these external investments of the 
organ. We lincl lymph, matter, serum, and the various products 
of inflammation, thickening of the arachnoid membrane or of the 
dura mater, and vascularity of the pia mater ; but these all evi- 
dently are inflammation of the membranes. But of this ten- 
dency we again gather fresh evidence at every further step in 
the enquiry. If we examine the lungs, or rather the chest, for one 
inflammation of the substance of the lung, we meet wdth innume- 
rable examples of its being confined to the membrane (the pleura) 
which encloses them. Thus, what I remarked with regard to that 
continuation of the skin which lines the ramifications of the wind- 
pipe is also true of the pleura. Indeed inflammatory affections of 
the pleura are so common, that we find the majority of bodies 
which we examine presenting traces of inflammation in this part, 
just as we find that there are very few^ persons who, under the form 
of slight colds or more serious afl"ections, have not, at some period 
or other of their lives, been sub»ject to inflammatory action of the 
mucous membrane of their respiratory passages. 



285 



Dr. P. M. Latham, who is an industrious observer of facts, re- 
marks, in some lectures on affections of the heart, published in the 
Medical Gazette, that, in regard to the pericardium, the membrane 
which invests the heart, the inflammation of this membrane, as 
compared with its occurrence in the substance of the heart, occurs 
in a proportion so much more frequent as to be absolutely incalcu- 
lable. Those who have examined many bodies must be struck 
with this fact, if it have not already occurred to them ; and the 
general impression would be much stronger than it now is, if the 
fact were so well known as it is to Dr. Latham and others, who 
have had much experience in such examinations. The truth is, 
that we not only find this inflammation very common, but we find 
it where no symptoms during life had led to its detection or 
suspicion. 

You know that the abdomen is lined, and all the viscera are 
covered (with exceptions not worth noticing), by a serous mem- 
brane ; and here we find again the same kind of evidence ; that is, 
that the external covering of the viscera is affected in an exceed- 
ingly large proportion of instances as compared to inflammations of 
their actual structure : so that here we see, in all the great cavities 
of the body, all the habitations of important organs, the same 
tendency to the surface. We know also, that, great as is the evil 
of inflammation of such surfaces, it is much less than when inflam- 
mation occurs in the actual substance of the respective organs. 
But inflammatory action is still less mischievous when it occurs on 
the mucous aspect of the respective organs, which are provided 
with such a structure, communicating with external parts ; and, 
when it occurs on the actual surface of the body, it is less injurious 
than in any other situation. Before we proceed, then, in examin- 
ing particularly any more facts, we will announce the law to which 
the phenomena already collected seem to point ; and then we will 
test its application to the phenomena which we have next to con- 
sider ; not forgetting, in the conclusion, those which seem to offer 
the greatest and most difficult exceptions to it. 

L The law, then, is, that inflammation is essentially a repara- 
tive process, and that, where the repair required is that of local 
injury, it is of course referred to the seat of such injury : in all other 
cases, it is a process instituted by Nature to get rid of injurious 
influences, by determining to the surface of the body. 

2. In all laws, certain interferences happen w^hich appear as ex- 
ceptions, until such interferences are duly understood and explained ; 



286 



when, of course, on removing objections or doubts in regard to the 
operation of such laws, thej become either supporters of their 
probability or demonstrators of their truth, in affording an addi- 
tional number of phenomena in subservience to them. 

3. To carry out a natural law implies the condition of natural 
power, or a condition approaching thereto ; and therefore the ab- 
sence of natural power will be a competent explanation of the 
deviation from such law : if this abseDce be only probable, it will 
then be only a probable explanation of the deviation in question ; 
if demonstrable, it will be a real explanation of it. 

I would however, in limine, observe, that, though the expres- 
sion of the law which 1 have used above may be substantial truth, 
yet it may possibly not express the actual law, but only something 
in approximation to it ; since the various actions may belong to 
some law, of which they, and perhaps a multitude of phenomena 
which appear at first sight very different, may be the common ema- 
nation ; but this is not, perhaps, important. If the facts be true, the 
step may be shorter ; but the progress in science will not be less in 
feet, but in degree. In the inflammations about to be considered, it 
will be an essential element to shew that they are characterized by 
some previous or concurrent disorder of the general oeconomy, 
disturbing natural power. 

Begging you to recollect, then, what I said some pages since, as 
to the necessity of examining a chain of phenomena, link by link, 
in order to recognize the counection, I begin with a few remarks 
on gout. 

You are probably aware that the usual history of gout informs 
us that it generally occurs about the middle or towards the decline 
of life ; that it is most common in those who have the power of 
living easily, not to say always luxuriously ; that, as happens in 
regard to most other diseases, we can, ccFteris paribus, usuallj' trace 
something of hereditary influence in the disposition to it ; that its 
occurrence as an external disease is often very sudden. A man, 
perhaps, going to bed pretty well, or at ail events without pain, is 
suddenly awakened by a tremendous pain in his toe. He conti- 
nues restless ; and, examining the part, he finds it red, swollen, 
very hot, and throbbing. The pain varies in all conceivable de- 
gree, from slight uneasiness to actual torture. Ordinarily, the pain 
is very considerable. 

Now we believe the disease to depend on some disordered con- 
dition of the system; and this, notwithstanding tliat many patients 



287 



date its occurrence from an accidental injury : and all the world 
agree in this belief, although, generally, they differ as much in 
regard to diseases as on any subject whatever. The agreement in 
opinion may not extend to the particular kind of disorder, nor 
the kind of remedy most proper for it : you may readily conceive, 
however, that the facts must have been very numerous and striking 
to have achieved even that general coincidence of opinion which I 
have mentioned. In truth, these facts have rendered the conclu- 
sion to which I have referred irresistible. This will save us from 
any lengthened discussion ; and I will only mention, in a cursory 
manner, some of the facts in question. Many cases, where people 
have not complained immediately before the attack, are found, ne- 
vertheless, to have been preceded by a very palpable state of indis- 
position ; such as nausea, deficient appetite, listlessness, or inapti- 
tude for exertion, irritability of temper, a curious, unsettled, 
fidgety condition of the system. All or any of these, and a great 
many other sensations, less describable, generally admonish a 
patient that he is not well. Some who have had repeated seizures 
will foretell an attack of the gout by their sensations, although they 
are quite unable to particularize or explain what their sensations are. 

Then the occurrence of gout frequently relieves various preced- 
ing disorders of the system ; and this fact was so familiar a long 
time since, that, even within my own recollection, it was no very 
uncommon thing to hear of a person going to this or that place, in 
the hope of getting the gout to carry out, as it was termed, some 
other disorder. Bath was a very common rendezvous for people of 
this description, 

Occasionally, aiso, gout has been suddenly repelled from the 
surface, sometimes by the imprudent application of local remedies, 
at others by influences accidentally administered ; such as catching 
cold : and, in such cases, patients have generally had some highly 
dangerous attack of some internal organ, more frequently, perhaps, 
the stomach or the brain than any other ; and these attacks have 
very frequently proved fatal. 

The subject of gout also knows perfectly well that the occur- 
rence of the disease is materially influenced by diet ; and this 
knowledge is so universal, that even those who do not arrive at the 
very obvious fact, that habitual moderation is the essential thiug, 
still have learnt to appreciate the influence of particular substances ; 
so that you hardly ever meet with a gouty person but you find that 
there is some substance or other from which, however incautious he 



288 



may be in otlier respects, he habitually abstains ; or, if he does 
take it, it is with a very vigilant moderation ; whilst, generally, 
persons subject to this disease have a considerable catalogue of 
things which experience has told them they can neither eat nor 
drink with impunity. The most common are butter, fat, pastry, 
fermented liquors, or particular beverages, as beer, port-wine, 
punch, and the like. But patients who can take them with impunity 
are generally obliged to observe moderation, or to be constantly 
taking medicine*. 

Quacks have, at different times, given specifics for gout ; and 
these, as is generally the case, however prejudicial, generally afford 
the philosophical enquirer some evidence of the nature of disease. 
So, where they do not prove fatal, as was too often the case with 
the Eau Medicinale, they occasionally quickly rid the person of the 
disease. But we always find that it is by the vigorous excitement 
of some one or more — occasionally several — of the secretions ; co- 
pious discharges from the skin or kidney, stomach or bowels, and 
sometimes from all these sources ; the simultaneous disappear- 
ance of gout shewing its connection with the particular condi- 
tion of the system at large. Lastly, the evidence of this, the local 
manifestation of disease, which we call gout, being an indication of 
general disturbance, is seen in the effects which certain moral 
influences have both in its causation and removal. Nothing is 
more frequently observed, than that mental inquietude in those so 
disposed will produce a paroxysm of gout ; and, on the other 
hand, cases are not wanting which shew that peculiar moral in- 
fluences will occasionally drive away gout as quickly as they will 
produce it. It has been know-n that a violent fright, such as a fire 
occurring in the house, has enabled a gouty patient, who could not 
set one foot before the other, to effect his safety by a retreat, just 
as nimbly as those whose limbs were in their natural condition. 



* Sydenham says that gout most commonly seizes old men who, amongst other 
things, have allowed themselves "free banquets, wine, and spirituous liquors," 
who are of a " gross habit of body," &c. (page 341 — Works), or who have 
hastened old age by intemperance, &c. — 349. 

Cullen, that " gout attacks men of large heads, full and corpulent bodies, 
seldom occurring in eunuchs ; that, amongst its causes, are sedentary habits, full 
animal diet, large use of wine or other fermented liquors," &c. (pages 56 and 57, 
vol. ii) ; and that " a plethoric state, inducing debility, is most favourable to it." 

Morgagni, that " the gout is a disorder of the rich, seldom one of the poor" — 
page 5^. 



289 



Another cause, which has opened the eyes of mankind to the connec- 
tion of this malady, and indeed of many others, with the general con- 
dition of the body, is the entire inefficiency of local remedies ; that 
is, those which can alone be safely employed. Warmth, either moist 
or dry ; occasionally leeches ; and, where it can be borne, gentle 
frictions ; compose, I believe, the whole catalogue : and no one 
uses these with any hope of doing more than relieve the disease, or 
of keeping it from " flying" to some more dangerous part. I believe, in 
fact, that any idea of remedying materially the disease by local 
means is abandoned : that neither the most ignorant qaack nor the 
best-informed person ever think of attempting it. I have not 
thought it necessary to illustrate the several foregoing facts by 
cases ; but any book will furnish them : they are so notorious, that 
any specific evidence is superfluous. It is, however, necessary 
that you should remember also, that although the disease is of an 
essentially inflammatory kind, yet general bleeding is still less prac- 
tised than local bleeding. I do not mean to say that gouty patients 
are never, still less that they should never, be bled from the arm ; 
but still, when thej' are, it is never done with a view of curing the 
gout, but as relieving a state of system characterized by unusual 
fulness, which is regarded as unfavourable. But, whether with 
this or with any other intention, bleeding in this kind of inflam- 
mation is seldom practised; and where it is, it is not only not re- 
garded as an influential remedy, but it is employed with the 
greatest caution. The local characters of gout are not without 
their interest, nor indeed without their bearing on the general 
argument ; but it is unnecessary in regard to a disease whose 
connection with disordered conditions of the system is so generally 
acknowledged. 

The pain, &c. of gout, is referred to the joints ; but the inflam- 
mation is almost entirely external to them : so that it is not until 
after frequent attacks, that we find even the external structures of 
the joints really injured. It is, in this respect, analogous to a vast 
number of other cases of disturbance in joints ; the inflammation 
is established external to them, that is, nearer to, or on the surface, 
as will be again remarked on as w^e proceed. 

The nature and varieties of the connection before mentioned 
ought to be explained ; but this is proper for a book especially de- 
voted to the subject, and one, so far as I know, still wanted. Now^, 
then, to review the facts of gout. We have an inflammation oc- 
curring on the surface, obviously connected with a disordered state 

U 



290 



of system, and which state it has a direct tendency to relieve ; 
also in which those measures, usually considered most potential in 
common inflammation, are not only useless, but so injurious as to 
be usually out of the question. 

The next inflammation which I propose to consider, that is, — so 
far as it unfolds to us, or throws any light on the real causes of 
imflammation, — is a disease more common in the young, as gout is 
more prevalent in adult or advancing life ; — I mean scrofula. I 
shall hereafter have to speak at length of this disease ; I have only 
here to consider it in its relation to inflammation. In the first 
place, the essential facts so notorious in gout, are equally ac- 
knowledged in regard to scrofula ; — viz. that it is, wherever oc- 
curring, to be regarded as a disease of the body generally, of which 
those local actions characteristic of the malady are merely 
indications. The reasons which appear to have led mankind to 
this conviction, and, at all events, which prove the fact, may some 
of them be briefly stated. Scrofula chiefly attacks persons of dis- 
tinguishable temperament. Its sabjects are most commonly fine 
skinned, what would be usually called good complexions. This, 
like many other characteristics of scrofulous tendency, is not uni- 
versal ; but perhaps it is the most general. Individuals of fair com- 
plexion, light hair, &c. are said to be especially subject to this 
disease ; but this is by no means so general : hundreds of persons 
with dark hair, &c. are affected by scrofula. 

It is well known that children often exhibit a tendency to the 
same disease as their parents: this is exhibited in many dis- 
eases ; but in none more remarkably or more constantly than in 
scrofula. 

It must be borne in mind, however, that in no disease is any 
development of this tendency necessary : therefore, notwithstand- 
ing the general truth of it in regard to scrofula, yet there are many 
exceptions. Scrofula affects all parts of the body ; no structure is 
necessarily exempt from, or at least uninfluenced by, it. It is 
also materially influenced in its development, its progress and 
termination, by any thing which tends to derange the general oeco- 
nomy : of the various channels through which these influences 
act, none seem more frequent than the skin, lungs, and digestive 
organs. With regard to the skin and lungs, scrofula is most com- 
mon in variable climates, as that of Great Britain generally ; and 
it is interesting to observe, that change of climate will develop 
scrofula very actively, and fatally, in those in whom no scrofolous 



291 



tendency was before observable. Animals, man iuclusive, when 
brought to England from tropical climates, become very subject to 
scrofula ; scrofulous disease, and of the lungs especially, is to them 
the peculiar danger of our climate. Monkeys, lions, &c. are very 
apt to suffer from scrofula ; of which the Zoological Gardens and 
other similar collections furnish frequent examples. Notwith- 
standing that these and many other similar facts very decidedly 
point to the influence of vicissitudes of temperature as producing 
this peculiar disease, yet they are, perhaps, not more frequently the 
cause than derangement of the digestive organs ; and they may 
often, perhaps, owe their influence on the animal oeconomy to the 
previously disturbed conditions which always attend disorder of 
those important functions, and which invariably diminish our 
power of resisting noxious influences. 

We never find the digesMve organs healthy in scrofula ; at least, 
out of hundreds of cases, I cannot recollect one wherein there was 
not a very detectable disorder of some of the chylopoietic viscera ; 
unless indeed at a time when the patient w^as under treatment, 
which was so far successful as maintaining an apparently quiet 
condition of these organs. 1 lately had a case of strumous oph- 
thalmia in the Dispensary, which, on a hasty examination, might 
by some persons have been regarded as an exception to this state- 
ment. The patient, a child, appeared to be in good health ; and, 
what is certainly not common, the tongue was not only perfectly 
clean, but in all respects perfectly healthy ; in fact, the only indi- 
cation of anything wrong, was that the bowels were costive : I 
therefore gave the child moderate doses of rhubarb, and, in a few 
days, the eye had recovered : yet I have no doubt, had I given 
calomel, or some additional medicine, and put a leech or two or a 
blister behind the ear, the recovery would have been attributed to 
these measures as much as to the simple circumstance of regulating 
the bowels. 

Now, in animals brought from warm climates, notwithstanding 
that their habits, and, to a certain extent, their food, will be different, 
yet various circumstances render it reasonable to infer, that change 
of temperature or climate is the chief cause : but, on the other 
hand, scrofula occurs in animals vv'here we must attribute it, on the 
contrary, chiefly to change of food and habits. Rats, cats, rabbits, 
especially, are subject to scrofula; but, without taking upon me to 
say that the contrary never happens, I believe it is almost always 
in a tame or domesticated state. Birds are also subject to scrofula, 

U2 



292 

pigeons particularly : but here again the same observation is appli- 
cable. Now all this points, not wholly, I admit, but chiefly, to the 
digestive organs. The treatment of scrofula still more strongly 
confirms the intimate connection of the disease with the general 
oeconomy. But I have said enough for the moment ; and now, 
then, let us apply it to scrofulous inflammation. Scrofulous in- 
flammation, as every one knows, occurs most commonly near the 
surface of the body. For one case wherein the lungs or mesen- 
tery (notwithstanding the terrific frequency of the former) are pri- 
marily aff'ected, a vast number occur in the joints, skin, — in fact, 
near the surfaces of the body ; and here again we see a beautiful 
illustration (by what we are accustomed to regard as internal parts) 
of the continued agency of the two great excitants of scrofula, — 
viz. climate and food. 

Those parts aff'ected in frequency, next to those near the sur- 
face, being the lungs on one hand, and the mesenteric glands on 
the other, — the first portals, as it were, through ^vhich the newly 
converted food passes to reach the circulation, — it is curious also 
to observe, that, as the inflammation is instituted in parts where, 
practically, it proves least injurious, so it is in these examples that 
we find the greatest approximation, remote though it be, to what 
we regard as the character of healthy inflammation ; in other 
words, those parts where the inflammation is least injurious aff"ord- 
ing most exhibition of power. Thus, if we have ophthalmia, or 
glandular swelling, it is here that we have heat, swelling, and red- 
ness,— -phenomena most nearly simulating the characters of common 
inflammation. But if scrofula attacks joints, then we have so little 
exemplification of these features of common inflammation, that 
although, quoad the joint, the eff'ect to determine the action to the 
surface is partially successful in the efi'usion which takes place 
around it ; yet so far is this from being thrown to the surface in a 
healthy or preservative manner, that the skin is actually paler than 
usual, so as to cause these affections to be called " white swel- 
lings* ;" whilst, in the lungs and mesentery, scarcely any type, even 
of that which constitutes the ordinary features of healthy inflam- 
mation, is observable. 

Well, T say scrofulous inflammation occurs most frequently on 
the surface. A child has a swelling in the neck, a part usually 



* Not that the scrofulous ciffectioxis of the joints are always unattended by red- 
ness of the surface covering them. 



293 



most exposed, or soir.e gland in some other part is affected, or 
there is the peculiar strumous ophthalmia, or perhaps some joint is 
affected ; the two former being the usual manifestations. We 
recognize, in the treatment, all the circumstances which I have 
mentioned ; yet the part is red or swollen, and has the general 
character of a modified inflammation ; but we recognize the local 
effects, like those of gout, to be peculiar, and thus confirming our 
notion that the disease does not wholly consist of vascular dis- 
turbances ; we never think of curing scrofula by bleeding. We 
may, in certain cases, abstract blood, as in gout, and with different 
intentions ; but still, not to cure the disease. If we take blood in 
strumous ophthalmia, — which, by the way, is oftener necessary in 
practice than it ought to be, — we do it not to cure the inflammation. 
I have been accustomed to explain it thus : — you know that you 
may have all other symptoms of strumous ophthalmia for months 
without the organ being injured ; but not so with the inflammation ; 
because, if the eye becomes injured as an optical instrument, it is 
by the thickening of parts that should be transparent : it is the 
inflammation which does this ; and therefore you may be obliged, in 
the absence of being able at once to correct the condition of the 
system, on which the disease depends, to moderate this particular 
symptom by the abstraction of a little blood from the part : but 
you are so far from curing the disease, that, if you are not careful, 
you exasperate it by the very bleeding which }'0u intend to do good. 

Here, then, is another disease in which inflammation is a 
leading feature ; in which inflammation appears even to produce 
the material change in structure; and yet which is clearly an ex- 
ternal evidence of general disturbance, and which you attempt to 
relieve by means directed to the general oeconomy, and in which 
your are so far from bleeding, that, if you know what you are 
about, you carefully avoid it : so that, as regards the chain, the 
links of which I am endeavouring to shadow forth, it would, per- 
haps, have been better to have put scrofula first ; in which, both as 
regards the character of the disease, and the benefit of anti-infl;im- 
matory remedies, it is less an instance of inflammatory, and more 
an example of general disease, determining to the surface, than even 
gout itself*. 

* In both diseases, excitement is unquestionabl)'- prejudicial ; and hence it is, 
that, with a view to give strength in scrofula, a diet is often allowed which is 
highly injurious : but, important as this subject is, I cannot -enter further into it in 
this place. 



2<)4 

We have certain inflammations of the following kind : — the 
patient feels a pimple, rather tender, it gradually becomes painfal, 
the part is stiff and imeasv, and, if in a situation subject to pres- 
sure, this must be avoided. At length, the pain, swelling, and 
tenderness increase to a most tormenting degree, when, becoming 
almost intolerable, the swelling bursts, discharges a little matter 
tinged with blood, a little ragged cellular tissue, and all is over. 
Here, then, is a common boil"^. If this boil occur with greater dis- 
turbance of the health, — if it progress more slowly, — if it form less 
of a swelling, but extend to a greater district, — if it feel hot, hard, 
and brawny, — and, if not bursting, a section be made of it, — and this 
expose the subjacent cellular tissues in a state of quaggy slough, 
discharging more or less of blood and matter, — why then we call it 
a carbuncle. 

If again all these characters are increased, if the pain be ex- 
cruciating, if the parts assume a fiery, yet li^-id, lead-like appear- 
ance, with the gorged veins she^rag their purple ramifications, 
we say it is an anthrax ; so that, what I wish you to understand 
is, that, although these diseases are very different in their various 
degrees of danger and severity, yet that they all belong to the same 
fomily, and have many things in common, and this both in their 
local character, and in their relations to the general economy. 

Now we have the local character of inflammation in all these 
diseases highly developed ; I mean we have great e^'idenee of in- 
creased vascularity, redness, heat, pain, swelling, and tlirobbing ; 
and yet we do not treat them by what we are in other cases taught 
to be the great principle in the treatment of inflammation ; I mean 
by depletion, or by reducing the general powers of the system : on 
the contrary, boil only excepted, in which scarcely any treatment 
is necessary, we rather moderate than reduce excitement, and en- 
deavour to support rather than depress the vital energies. We do 
this, because we perceive that the inflammation, though truly 
enough inflammati.on, is but the indication of a general disorder of 

* The connection of boils wirh the general health is recognized very disrinctly 
bv the older surgeons ^,vho have -.vritten in regard to it. Thus, Wiseman remarks 
that " boil proceedeth from a gross, vicious blood, separated from the rest as un- 
profitable, and is cast forth b;.- the strength of Narure into the external parts of 
the bony.'"" — "Wiseman's Chirurgical Treatises, p. 42. 

Heister says (System of Surgery, p. 195), " that the cause of boils is a too 
glutinous r':d inspissated state of the blood ; and that, when they are nmnerous, 
they require •imernal purging medicines," and such as attenuate, and purge, and 
cleanse th.. Idood.'' He also says, that a strict regimen of diet should be used. 



295 



the system on which it depends ; and the facts which point to this 
— I mean independently of the failure of such treatment— are the 
following. Boils are well known to be connected with a certain 
condition of the system : this is different in different cases : some- 
times there is a fulness of system ; sometimes indigestion ; some- 
times costive bowels ; and sometimes the condition is not easily 
referrible to either of these, certain people being liable to be affected 
by them whenever they are otherwise indisposed. In many, any 
irritation on the skin will produce them ; and hence they are com- 
monly enough the sequelae of blisters. Many persons are relieved 
by them, so that they express themselves as feeling better after 
their occurrence than they have felt some time previously : thus they 
are often popularly considered as purifying the blood, as the phrase 
is ; all of which facts concur in establishing their connection with 
disordered conditions of the system. As these are well known, let 
us proceed to carbuncle. This is alwa}'s a highly inflammatory 
disease, and one very demonstrably connected with disorder of the 
health, a very prominent feature of which (in my experience in- 
variably) is a derangement of the chylopoietic viscera. It is a 
curious fact, that they generally occur on the posterior surface of 
the body, to which we observe some tendency in boil. But, in 
carbuncle, the tendency is very remarkable. They also happen, in 
the great majority of cases, in persons who have lived well, as they 
phrase it, or w^ho have been easy or luxurious in their habits ; and 
Mr. Hunter says, he never had but one patient with carbuncle in 
the hospital ; and this was a man who had been a gentleman's 
butler, — a class of persons who understand and indulge in good 
eating and drinking to an extent which is well known. I have, 
how^ever, seen carbuncle occasionally in people whose history did 
not furnish any satisfactory evidence of luxurious or full living. 
Carbuncles are certainly much more common, now, amongst the 
lower classes of life than the foregoing observation of Mr. Hunter 
might lead us to imagine. I have seen a great number of them in 
my time in dispensary practice ; so that I cannot regard them as 
uncommon, or even unfrequent, occurrences. It is very probable 
that gross or full living may be that kind of intemperance which 
most frequently leads to their occurrence ; but tlie essential thing 
seems to be any mode which disorders the animal ceconomy, and 
yet leaves it a certain degree of povv'er. The great interest which 
results from seeing many cases of this kind consists chiefly in the 
emphatic manner in which that connection between boil and car- 



296 



buncle, wLicli is so iiuiversally recognized, becomes demonstrated, 
as that also which marks anthrax as a more dangerons member 
of the same family. The recognition of the constitntional con- 
nection of all these diseases, though dressed in the language of the 
humoral pathology, is constant in nearly all old writers on surgery. 
The worst case of carbuncle I ever saw was in a butcher ; and it 
is the only case of that form of the disease to w^hich the term 
anthrax has been applied, that I had reason to regard as a genuine 
specimen. The moment I saw the case, I recognized the descrip- 
tion I had heard of it ; and especially what I had heard Mr. 
Abernethy say in regard to it. I accordingly pronounced the case 
anthrax; but I was much gratified in being able to obtain the 
concurrent opinion of a gentleman who had seen a good deal of 
anthrax, in connection with the plague, and who agreed with me 
that it was a genuine case : this was Mr. Davis, of Hampstead : 
As the case is rare and instructive, I shall relate it, and in the pre- 
sent volume ; but it will be more conveniently done in connection 
with the treatment of these diseases. 

It should be observed, that, although we recognize boil, car- 
buncle, and anthrax, as different diseases, in consequence of 
the different degrees in which their symptoms are developed, — yet 
their general characters being the same, and the degree in which 
these are developed endless, it follows that these diseases will be 
shaded off into one another, so that many examples may be re- 
garded as connecting links betw^een these undoubted members of 
the same family. Thus, a very severe boil, or a very slight car- 
buncle, is not a distinguishable disease ; and T have seen another 
variety in which the progress was that of carbuncle ; but the ter- 
mination neither that of boil nor carbuncle, but in fact more that 
of common abscess, the contents being well-formed, inodorous, but 
very thick pus. Artificial arrangements of diseases are mis- 
chievous ; but natural relations, even though much less distinct 
than are those of boil, anthrax, and carbuncle, should be carefully 
regarded. 

In all these diseases we remark that there is great excitement ; 
and in general, in the severer forms, little power : even in common 
boil we are not without evidence of both these in less marked de- 
gree. A boil is always attended by the death of more or less of 
the cellular tissue ; and that this is not merely consequent on the 
degree of excitement (which, if vehement, may cause sloughing 
under any circumstances) is shewn in that its occurrence is not regu- 



297 



latedjiu the abstract, b J the violence of the excitement: in other words, 
we see a bit of sloughy cellular tissue, just as regularly in small or 
trifling boils as we do in severe ones. But this evidence of want 
of strength is more marked in carbuncle, and was very remarkable 
in the case of anthrax which will be related. So that any thing 
like large abstraction of blood, or indeed very powerful depletion 
of any sort, is out of the question. On the contrary, whatever the 
particular case may oblige us to do, and the indications will be 
different in different cases, we are careful to support the strength of 
the patient. In carbuncle, the evidence both of exciiement and 
weakness are, in the local character, very marked also. The evi- 
dences of increased vascular action are seen in the extent of the 
redness, in the pain, heat, and throbbing ; while the weakness is 
seen in the extent of the mortification of the cellular tissue. The 
section of a carbuncle is usually made with a view of expediting 
its progress, exposing iil-forraed pus, with considerable quantities 
of sloughing cellular tissue ; nor are we to regard this sloughing 
as the direct consequence of the excitement, since the same degree 
of excitement may take place, whilst the effects produced are very 
different ; as in a common phlegmonous abscess : it is rather (I 
mean the sloughing) to be regarded as the joint result of excite- 
ment, acting on parts whose vital powers are, from some cause or 
other, diminished*. 

Now here we have another set of inflammatory actions, well 
marked, highly developed, in which we observe these processes set 
up on the surface of the body, and their relation to the general 
oeconomy, differently manifested in different cases, it is true, but 
still so intimately connected with some disordered state of the 
system as to be very unequi^^ocal. Nor does the treatment point 
less to this connection than the history ; since, with the exception 
of free incisions to expedite the separation of the sloughs, and 
poultices to facilitate their ejection, it is w^iolly directed to the 
general system : but that I shall describe in detail. I only mention 



* I consider inflammation as an increased action, &;c. ; but, in inflammation 
which terminates in mortification, there is no increase of power ; but, on the con- 
trary, a diminution of it. This, when joined to an increased action becomes a 
cause of mortification, by destroying the balance which ought to subsist between 
the powers and actions of every part. There are, besides, cases of mortification, 
preceded by inflammation, which do not arise wholly from that as a cause, but 
rather seem to have something in their nature. Of this kind are the carbuncle 
and the slough formed in the small-pox pustule. — J. Hunter, op. cit. p. 8. 



298 



it now as tending to shew the nature of this disease. These dis- 
eases also afford another example of inflammation, in which the 
abstraction of blood is not employed ; in which, in fact, the cure is 
principally conducted bj influences directed to the remote causes, 
and properly the real causes of the malady. 

Thus far we have considered processes in which, notwithstand- 
ing that the local characters presented are those of inflammation, 
we either bleed very sparingly or do not bleed at all ; or, on the 
contrar}', adopt a plan as much calculated to keep the quantity of 
the blood at par as to diminish it. In tracing, however, the chain, 
as I may term it, of inflammatory actions, we now come to a dis- 
ease of a difl"erent aspect, and one in which we, for the first time, 
observe something which is a more decided type of what is ordi- 
narily regarded as the leading feature in the treatment of inflam- 
mation ; that is, bleeding or some other mode of depletion. I say 
type of this practice ; for nothing is more varied than is the treat- 
ment in different hands of this erysipelas^ the disease concerning 
which I am going to speak. 

The local phenomena of erysipelas are characteristic. They 
are often, indeed generally, preceded by a sensation of chilliness, 
or coldness of the skin, which is soon followed by some sense of 
heat, occasionally itching ; the redness gradually extends to a 
greater or less distance, accompanied by a general enlargement of 
the limb, or swelling of the part, or both. We can neither trace 
the exact boundary of the svrelliDg or of the redness ; but both 
seem to be gradually shaded off, as it were, till we arrive at the 
hitherto healthy district of the limb. At this time, there is some 
evidence of general excitement. The pulse is usually frequent, 
and with a degree of sharpness in its beat ; and, if the arm or 
hand be affected, in addition to the characters I have mentioned, 
the pulse will be stronger and even fuller on that side. You may 
have the pulse either hard or net in erysipelas : the characters 
above mentioned are the most constant. The tongue is furred ; the 
bowels usually tendmg to costiveness ; and, if their secretions be 
examined, they will generally be found unhealthy ; the appetite 
fails ; but this is by no means invariably the case in this stage of 
the disease. Sometimes there is tenderness on some district of the 
body, as the epigastrium or right side ; so is there pain in the head ; 
sometimes a distressing prostration of strength, the patient sapng 
you could " knock him down with a featlier.'' In short, the indi- 
cations of general indisposition vary iu kind and degree ; but they 



299 



are constantly present in some form or other : the main point is, 
that the evidence of general disorder is always present ; nor is 
the seat of the canse of this indisposition, in general, difficult of 
discrimination, if we examine with the requisite attention. 

If the disease is to proceed, the swelling and redness increase, 
the latter generally assumes a somewhat deeper shade. We ob- 
serve elevations of the cuticle (blisters) ; the subjacent skin gradu- 
ally sloughs, or sometimes opens partly by sloughs and partly by 
ulceration ; and matter ill-formed, blood tinged with shreddy 
sloughs of cellular tissue, are discharged. These matters continue 
to be discharged for some days, usually attended by loss of more 
skin, either by sloughing or ulceration, or a mixture of the two. 
i\t length, however, the redness and s^velling begin to diminish ; 
and granulations begin to form in the wound : these gradually 
occupy the destroyed surface ; new skin commences to form at the 
edges of the wound, which now heals slowly, but in the usual 
manner. 

As I still have a great deal to say on the treatment of this 
complaint, I merely advert to erysipelas here, so far as is necessary 
to the argument I am pursuing, with a view to develop the real 
causes of inflammation. Now, whether erysipelas occurs sponta- 
neously, as it is called, — that is, when we cannot perceive its cause*, 
— or when it is excited by a wound, we nevertheless see plenty of 
evidence that it is something in the general oeconomy which de- 
termines the particular kind of inflammation ; and, at all e\'ents, 
that there is some accompanying disturbance. 

We have erysipelas sometimes affecting the skin very super- 
ficially, and not doing more than just stripping ofl" the cuticle, and 
shewing a secreting or superficially ulcerated surface of the skin 
beneath it ; and this is called erythema : sometimes the cuticle does 
not separate at all, the erythema gradually disappearing or extend- 
ing itself to adjacent parts, whilst it leaves those it first occupied. 



* T lately saw a case which was far more interesting to me than what are gene- 
rally called good cases, as marking the continued chain in which, in Nature, dis- 
eases are linked together. Mr. Leigh visited a dispensary patient, a young woman, 
who had erysipelas of the leg, and was of healthy appearance, but with disordered 
secretions, and who confessed that she was in the habit of drinking spirits. He 
gave her some medicines to correct her secretions ; and, on its being reported that 
she was not so well three days afterwards, I visited her. The erysipelas had dis- 
appeared, and she now laboured under a slight form of continued fever. She did 
well. 



300 



In other cases, tlie erysipelas affects the slim, and the subjacent 
parts chiefly, the cellular tissue, or subsequently the fasciae beneath 
it* ; and then those circumstances follow that I have stated at the 
commencement of this section. Occasionally, the swelling, red- 
ness, pain, tension, are marked by great vehemence of action; 
the part becomes of a deep or even dusky red ; elevations of cuti- 
cle, having black spots of skin, occur in several places, indicating 
points of slough ; the health is very disturbed and excited ; and 
this we call phlegmonous erysipelas, — as if it were, par excellence, 
that species characterized by most marked inflammatory action. 
But you see that I here talk of a disease, again, which occurs 
at the surface of the body ; and, in its worst cases, seldom affects 
more than the skin and cellular tissue beneath itf. And, although 
inflammations occur in other parts which are supposed to be allied 
to erysipelas (and I think justly, in that they are evidently un- 
healthy), yet we cannot at present produce, perhaps, any example 
of the same kind of inflammatory process any where else but at 
the surface of the body. 

The particular seats of erysipelas will be again considered in 
the chapter which expressly treats of this malady ; when I shall add 
some further remarks on the subject of erysipelatous inflammation, 
occurring in other districts than the surface. In the mean time, it 
is interesting to observe certain points, in connection with ery- 
sipelas, as either primarily or secondarily affecting the skin. It 
would seem as if, when the general disorder was to be met by a 
light or fugitive inflammation, the actual skin at once becomes its 
seat, either solely or simultaneously with the subjacent cellular 
tissue. But, when the inflammation is to be severe or extensive, 
it begins first in the subjacent cellular tissue ; as in phlegm onoid 
erysipelas, sometimes called " diffused cellular inflammation."' 
Certain points of great importance appear to be gained by this 
arrangement. The ordinary function of the cellular tissue is com- 
paratii-ely unimportant : it is a much safer seat for extensive or se- 
vere inflammation than the skin ; and, if the skin is to perish, the 
primary establishment of inflammation in the cellular tissue at 
least modifies the effects which experience shews to result from 
sudden and violent attacks of this important organ (the skin). Be- 



* For further evidence of this, see Discourse on Erysipelas. 

t I have seen a case in which the fascia had sloughed away from the greater 
part of the lower extremities. 



301 



sides, we find practically tliat, in severe cases of this kind, the 
actual destruction of skin is by no means in proportion to the ex- 
tent of the cellular inflammation: in other words, a large portion 
of skin may be said to be saved by the arrangement. 

In reference to the treatment of this disease, there appears to 
have existed, at various times, the greatest difference of opinion : 
some resting on a practice chiefly, and in some cases even highly, de- 
pletory ; whilst others have said that support, carried even to bark, 
wine, and cordials, is the only judicious mode of proceeding. All 
this will be more fully discussed when I speak of the treatment of 
erysipelas : I here return to the chain I am tracing. 

Here, then, is another disease, decidedly inflammatory, de- 
cidedly appearing on the surface of the body, decidedly connected 
with disordered condition of the general health, and in which we 
first see active depletion commencing to be a part of the treatment, 
but with these reservations, — that its strongest advocates do not 
deny that, in some cases, it is unnecessary, in others, it may be in- 
jurious ; whilst another set of persons contend not only that it is 
urmecessary, but that a treatment should be preferred altogether of 
an opposite kind. One thing, however, they both agree in, which 
is a treatment which has this in common — that it is directed to 
produce an influence on the whole oeconomy. 

We have hitherto regarded, first the exemplification of that 
tendency of actions to the surface without any reference to inflam- 
mation, and secondly, as illustrated by a very common class of 
diseases, M^iich do exclusively occur on or near the surface, and 
which are decidedly inflammatory. 

If we follow up this appeal to the surface in another w^ay, 
review our first phenomena, and enquire what are the diseases of 
the surface, we find they are characterized by inflammation, and that 
the illustrations are infinite ; for, as I have already hinted, who shall 
count the various papular, vesicular, pustular, or tubercular erup- 
tions on the skin ? or who can deny that nine tenths of them — nay (if 
we are to extend our ideas of inflammation to increased action) all 
are characterized by — owe, in fact, their essential features to — inflam- 
mation ? What are myriads of pustules but inflammations termi- 
nating in suppuration — vesicles, in eflusion— papulee but increased 
actions in the part — or tubercles but inflammatory actions ter- 
minating in thickening or deposition ? That cutaneous diseases 
are also connected with disorders of the system is proved by the 
treatment required for their relief being necessarily, in the great 



\ 



:3U2 

majority of instances, addressed entirely to the interior of the 
body ; by the great danger notoriously consequent on their being 
suddenly repressed by any cause;* and by the tangible disorders 
of the system which either precede or accompany them, existing 
in so large a majority, that the small proportion of even apparent 
exceptions (and of which I know not any) bafHes calculation. 
But here again I must repeat that I am only adverting to, rather 
than considering at large, the evidence afforded by diseases of the 
skin ; which must necessarily be deferred until I treat of the 
diseases of this part as a separate subject. In conclusion, I may 
remark that diseases of the skin afford us another class of inflam- 
matory actions, in which bleeding is either very sparingly employed 
or not exhibited at all. Yet, in various cutaneous diseases, we 
have heat, redness, pain, swelling, effusion, suppuration, ulceration, 
sloughing, as already observed — all phenomena of inflammation. 

Now, then, let us begin to apply this to the foregoing argu- 
ment ; and let us enquire what light they afford us in regard to 
what is called common inflammation. By common or pure 
inflammation is generally understood an affection of any part of 
the body, in wliich the disturbance is thought to consist of inflam- 
mation in the part ; all the local symptoms are referrible to the 
vascular disturbance ; and any departure from the natural condition 
of the part — no matter what its nature — bears a proportion to the 
vascular excitement : I say, then, that, in pure inflammation, the 
symptoms are in harmony with the vascular disturbance, as to 
degree. For example : in the eye, we have inflammation, where, 
though the inflammation be trivial, the intolerance of light is ex- 
cessive ; and others where the vascular disturbance is very consi- 
derable, and yet there is scarcely any intolerance of liglit ; whilst, 
in pure inflammations of the eye, we find this symptom in very evi- 
dent proportion to the degree of inflammation. So, in inflammations 
of any other part — the pain in pure inflammation is in proportion to 
the vascular disturbance ; whilst in those which we call specific 
this relation cannot be perceived. For example : a great deal of 
inflammation, and of a very serious kind, may take place in scro- 
fula, without any pain, and often, too, in erj'sipelas, without any 
very great suffering ; v/hilst in common boil, though the disturb- 
ance occupy a small district, and the destruction of parts be in- 

* There is at this moment a patient in the dispensary, suffering from paralysis 
a fortnight after the disappearance of a boil ; but analogous cases, and indeed 
where the connection is much more striking, are very common. 



303 



considerable, the part is often torraentingly painful. But, if pure 
inflammation occur — of wbicli we see but few instances, and these 
chieflj the result of one kind or othei' of local injury — we 
find the pain bearing an evident proportion to the vascular dis- 
turbance. 

Further : in pure, common, or healthy inflammation, we always 
observe that it is circumscribed. This may be in the thickening 
round an abscess ; and, in almost every instance, its worst termi- 
nation is suppuration ; for, if any sloughing take place, we have 
more or less of departure from common inflammation ; and 
this we see even in common boil ; the excessive pain, the prover- 
bial tenderness, the constant sloughing, always present in greater or 
less degree, are departures from ordinary inflammation. Slough- 
ing hardly ever occurs from common inflammation, unless it be in 
consequence of the previous destruction of a part by injury or 
otherwise, and which therefore requires that it be separated from 
the body, as no longer able to execute its functions. And in com- 
mon inflammation the general disturbance of the system is so Kttle 
remarkable, and sometimes so imperceptible, that, notwithstanding 
the various links of the chain which I have hitherto been tracing 
point so directly to some disorder in the oeconomy, we seem to have 
inferred that, because we cannot percei\ e it, no such disorder exists : 
yet every day (so to speak) we are examining bodies where we meet 
with serious diseased changes, even affecting the mechanical functions 
of parts which were not, during life, suspected — which should alone 
be suflicient to prevent us from concluding that no disorder 
exists merely because we cannot discover its nature: for, to suppose 
that disorders exist of w^hich we can aee no S} mptoms, is to sup- 
pose a common and a probable occurrence ; w^hilst, to suppose a 
disease set up on the surface of the body — that is, a change in the 
actions of the oeconomy — without some cause referring to the con- 
dition of that oeconomy, is not only gratuitous, but irreconcilable 
with the facts just mentioned, and just as unreasonable as to sup- 
pose that a watch, which went regularly yesterdaj^, but w^hich 
loses twenty minutes to-day, would do so without some cause, 
merely because, not being a watch-maker, I cannot discover what 
that cause is. 

The truth is, that we talk of pure or common inflammation ; 
but in nature, except as instituted for purposes of repair, we seldom 
see it. Injuries are often followed by unhealthy inflammation; 
but healthy inflammation w^ithout injury is very rare. Healthy 



304 



inflammation is cliaracterized by the processes wliich I have men- 
tioned : bnt where do we see inflammation of the membranes, for 
example, present types of this healthy iuflammation ? Shall we 
look for it in the rapidly diffused inflammation of the brain, chest, 
or abdomen ? Yet that the circumscribing character of healthy _ 
inflammation is a function, not only natural, but even character- 
istic of the healthy condition of these cavities, is plain from the 
observation of their tendency to adhesion, from the manner in. 
which various local injuries are circumscribed by it; w^hilst 
that the limitation of such inflammation is evidently not solely 
influenced by the limitation of the injury, is clear from such 
a number of examples in which local injuries produce here, as in 
the skin, the dangerous diffusion of inflammation, unchecked by the 
healthy processes which are found to limit it. 

The foregoing considerations lead us to this point — that 
every inflammation we have adduced seems evidently connected 
with some disordered condition of the system ; that, in many cases, 
its occurrence is followed by decided relief of that disorder ; and 
that the inflammations concerning which these enquiries have been 
made, however various or dissimilar their shades, have this in 
common — namely, that they occur at the surface of the body. We 
now, then, have to ask, what right we have, a priori, to conclude 
that inflammations of a pure nature, as we term them, are less ex- 
emplifications of the same laws than those which are more glaring 
instances. For myself, 1 can see no reason whatever for the 
assumption, unless it be that the connection on which the law 
appears to rest is not equally perceptible, or perhaps I should say 
not equally demonstrable. 

It must be admitted that, if we expect the same kind of evi- 
dence of the connection of every inflammation with general disor- 
der of the body or of particular organs, as we find in gout, scro- 
fula, rheumatism, erysipelas, or the infinite variety of diseases of 
the skin, we shall be often disappointed ; nor is the seat of those 
inflammations, which ive hastily regard as specimens of pure, as 
they are doubtless of serious, inflammation, always on the surface 
of the body. If, therefore, we wish to refer inflammation generally 
to the same laws as those to which we would refer the inflamma- 
tory diseases which I Lave mentioned, w^e must at least shew the 
probability that there exists some condition of the system, or of 
particular organs, favouring the occurrence of inflammation, 
although we may not be able, strictly speaking, to demonstrate it 



305 



This is further incumbent on us, if the existence of such condition 
offer some explanation of the inflammation occurring apparently in 
exception to the law in question ; that is, not on the surface of the 
bodj. In the present state of science, and still more in the present 
state of medical opinion, the task may be difficult ; but it does not 
appear to me, if we approach the subject with our minds unbiassed 
bj preconceived notions, to be impossible ; still less does it involve 
any opinion that is founded on any other ground than facts^ well 
known and familiar. 

But here again we shall obtain assistance by looking at inflam- 
mation in relation to the various phenomena with which it is con- 
nected. And, first, with regard to what is called determination of 
blood to particular parts of the body, by which a congestion or 
fulness of vessels of that part is produced. Practically, we know 
that, on certain occasions, more blood is contained in certain parts 
than is natural to them. Of this, the brain, liver, and lungs are 
common examples ; and, in many eases, we have decided evidence 
that there is greater action of the vessels in parts so circumstanced. 

I put these propositions separately, because the one does not 
necessarily involve the other. Activity of vessels sometimes 
takes place without there being more blood in the part than is na- 
tural ; nay, it occasionally occurs in consequence of an opposite 
condition, as we observe in the throbbing which now and then 
succeeds severe depletion, and in those states of the system which 
have been so well commented on by Dr. Marshall Hall. Neither, 
in all states of real congestion, can we say that the vessels are 
really more active; so that, although the activity of vessels 
and congestion are often, and perhaps generally, coexistent, — it is 
neither" safe, nor is it necessary to the argument, to assume that 
they are invariably so. If we enquire into the causes of determi- 
nation of blood to particular parts, we find that they are very dif- 
ferent in different cases, — obscure in some, and in others very pal- 
pable ; while, in a few, perhaps, they altogether escape detection. 

As to determinations to the head, we know that disorders of 
the stomach, of the liver especially, and, indeed, of the whole or 
any part of the digestive apparatus, do very frequently produce the 
phenomena of inflammation. We now, indeed, begin to see the 
use of studying the sympathies of the body in considering the 
causation of disease ; but as I have dwelt on that subject at some 
length, it will be sufficient to remind you, that any one part may 
produce disorder of any other part ; and, a fortiori, of its vascular 

X 



306 



tissue ; for we can scarcely imagine any disorder in which the cir- 
culation of blood in a part is not more or less affected. 

But, if the condition of any one part can produce congestion 
in any other, two circumstances are immediately presented to us 
of great interest in the enquiry. The one is, that these effects 
will be most likely to be produced on an organ by any one with 
which that affected has a ready sympathy : the other, that, in the 
production of congestion, we have not only the most common, but 
really the essential, element of inflammation ; for, although con- 
gestion may take place without inflammation, inflammation cannot 
exist without congestion, — in other words, without more blood 
circulating in the part than usual. 

Let us then take a case. A gentleman being apparently well 
about three o'clock in the afternoon, feels, in the course of the 
evening, an uneasy sensation low down on the right side of his 
chest. Finding, towards the night, that it is rather worse than bet- 
ter, he takes a warm-bath, and loses about ten or twelve ounces of 
blood by cupping from the part, but without experiencing any relief. 
He goes to bed, however ; but towards three or four o'clock in the 
morning, he finds that his pain has increased ; he has had no sleep ; 
and, moreover, his breathiug, which had been short and painful, 
has become so restricted, that he can only breathe by very quick 
and short intervals. He sends for his medical man, and desires 
that he may be bled. After his medical man has duly examined 
the case, he concurs in the measure, and abstracts a large quantity 
of blood ; in the case alluded to, fifty ounces. He is exceedingly 
weak, so as to suggest the expediency of administering a table- 
spoonful or two of gruel ; but he does not actually faint. Well, he 
is kept quiet ; his bowels opened by saline aperients, and calomel 
and antimony ; his symptoms, relie^-ed but not entirely vanquished 
by the bleeding, gTadually subside, and he gets well. 

Another person, travelling in an open carriage, feels chilly, and 
is attacked, soon after his arrival, with similar symptoms, followed 
by similar results. 

A third, similarly circumstanced, from the same cause, or from 
having got wet in his feet, is similarly affected ; is less fortunate, 
and dies ; and examination discovers the results of inflammation, 
of which I have formerly spoken. 

Now let us endeavour to see what these cases teach. In the 
first case a very large quantity of blood was lost ; the secretions 
were acted on ; the supply diminished, and the patient recovered. 



307 



Yet a number of circumstances shew that the quantity of blood, 
though it might be the predisposing cause in such a case, was not 
the real cause of the malady ; for, on the morning of the day on 
which he began to complain, he had no symptoms of inflammation ; 
and yet we cannot suppose him to have had less blood at that time 
(especially if we take a reasonable time after breakfast) than he 
had at three o'clock in the afternoon. Yet, if the quantity of 
blood had been the direct cause of the malady, it must have been 
so. Well, then, you will say it was the predisposing cause. Sup- 
posing we admit this, as probably it was ; what induced the determi- 
nation of it to his lungs, or rather to his pleura? since whatever 
that w^as, I take it to have been reallj^ the cause of the inflamma- 
tion ; and, moreover, that if that cause could have been discovered, 
and successfully administered to, he would have got well, even 
though such ministering had not involved any bleeding at all. 

I need scarcely observe, that inflammation occurs very often, — 
in fact, always, so far I know, — under circumstances in which it is 
impossible to refer it to any sudden increase of the general mass of 
blood, or to any quantity which can (abstractedly) be regarded as a 
necessary cause of inflammation. The very cases, each carry 
with them their own proofs that we cannot do this ; since, not in 
one case in a hundred, can we, with the least probability, say that 
the general mass of blood was greater when the inflammation com- 
menced, than it was immediately antecedent to its earliest sym- 
ptom. On the contrary, in many cases (in which the inflammation 
is most clearly demonstrable), we are certain that the quantity of 
blood must have been greater before the inflammation was induced, 
because we find that the loss of a very considerable quantity, in 
many operations, is by no means an absolute security against the 
supervention of inflammation. 

It is therefore certain, that although the absolute mass of the 
blood may dispose persons to the occurrence of inflammation, yet 
that there is some other link in the chain of causation, and that 
this link is a more essential element than any relating to the qxian- 
tity of blood. Because, whilst inflammation occurs often enough 
without any general fulness of the system ; so general fulness of 
the system is common enough without any inflammation. We 
must, then, look for this element elsewhere than in the absolute 
quantity of blood ; and a more auspicious direction will evidently 
be that which determines more blood than usual to a particular 
part ; because that is, as I have before observed, a really essential 



308 



element in inflammation, inasmuch as no one ever saw inflammation 
without it. If we could discover this, we should find, in all pro- 
babihtj, that as the general quantity of blood in the body is not 
the essential thing to be considered, so a general diminution in that 
quantity is not the essential thing in the treatment. This we 
should rather be led to regard as consisting in the restoration of 
the equilibrium of the circulation, or an equal distribution of the 
blood ; and thus we should at once understand how we might re- 
lieve many inflammations, either with very moderate abstractions 
of blood, or without any bleeding at all ; and also, how it happens, 
that in cases wherein w^e bleed most largely, we are often un- 
successful. 

If the essence of a disease consist in more blood than usual 
being in a part affected, we can readily indeed see that diminish- 
ing the general mass of blood in the body must have a manifest 
tendency to diminish the quantity of blood in the affected part ; 
but it is reasonable to suppose, that, in drawing the blood from every 
part of the system, to relieve one particular part, organ, or district, 
we must incur some risk of doing mischief, if indeed we are to 
regard the imnecessary abstraction of blood from parts as of any 
consequence at all. Now, experience shews that this anticipation 
is founded on fact. Repeated observation has proved, that a very 
serious, enduring, and distressing class of maladies, prospec- 
tively, are not less really engendered by the abstraction of large 
masses of blood. The circulation becomes extremely disordered ; 
the nervous system very seriously deranged ; determinations of 
blood to particular parts take place ; and a state of system arises, 
not distinguishable from a very opposite condition, simulating, in 
fact, a state of plethora. 

The remedies, however, employed for a plethoric condition, are 
not only not adapted to this state, which so simulates it, but they 
are highly prejudicial ; in fact, they materially aggravate the ma- 
lady. I have seen examples of this myself; but the profession 
and the public are, as far as I know, indebted to Dr. Marshall Hall 
for first compelling attention to this important subject. Reasoning 
and experience, therefore, alike impel ns to the suspicion, that, 
however we may succeed in removing the immediate danger of in- 
flammation by the copious abstraction of blood, we are not adopt- 
ing the best remedy ; and that in many, even of our (so called) 
successful cases, we can hardly be said to cure the patient ; since 
we relie^'e him from immediate danger, at the expense of entailing 



309 



on him a disposition to plethora, an irre^ilar state of circulation, 
and a variety of other distressing symptoms arising therefrom. 

Nor must it be foro^otten, that even this success is not constant : 
cases are always occm'ring, in greater or less frequency, in which, 
however powerfully combated, inflammation destroys the part, or 
the patient, accordiDglyas it is seated in parts more or less essential 
to vitality. Now, although my meaning will sufficiently appear 
when I speak specially of treatment, I wish, at this stage of the 
enquiry, to guard myself against misconception. I wish not to be 
understood as advocating the relinquishment of bleeding in inflam- 
mation. When a patient's life is in jeopardy, it is undoubtedly our 
duty to regard the safety of the individual as that into which all 
other considerations must necessarily merge. Though we were 
ever so convinced of the prospective objection to the abstraction 
of large quantities of blood, still, in the real absence of other reme- 
dies, we are bound to administer that, or any other, which ex- 
perience may have hitherto proved to be the most effectual with 
which we are acquainted. It is as if a man were drowning, and 
we could reach him only by means of a grappling iron, or some 
instrament which involved the risk of injuring him : this would 
not deter us from dragging him out of the water. 

The conviction, then, that a remedy does not administer to the 
cause of disease, or even that it is proved by experience that it 
may entail injurious consequences, should not hold our hands from 
employing it where life is in danger, so long as science mai/ not 
have made sufficient progress to supply us with a better. Never- 
theless, it is very important that we should be alive to these ob- 
jections ; for in the perception of them lies that of the imperfection 
of our science ; and, unless this be perceived, we can, of course, 
never hope to improve it. This is so important, that it is, in fact, 
the mainspring which often forces on us the necessary observation 
and reflection on which all advance must necessarily depend. 

The history of mercury exemplifies this in a very remarkable 
manner. The frequent failure in the object it was designed to 
accomplish, and the deplorable states of system it so often pro- 
duced, together with occasional peculiarities of constitution for- 
bidding its employment, have been the chief circumstances which 
have led to what (notwithstanding the present extensive abuse of 
that mineral) must be regarded as an improvement in the adjust- 
ment of its claims in medical science. But " Incidit in Scyllam 
qui vult vitare Charybdim," applies with great force to the history 



310 



of this mineral. In avoiding the outrageous and unnecessary 
employment of it in syphilis, men have fancied that they have 
discovered a more enlarged use of it, as extensive as was its ap- 
plication in sypliilis itself. Thus, though now mercury is wholly 
withheld, or employed with great caution, in syphilis, it is admi- 
nistered for a thousand other complaints, in many of which it is 
entirely unnecessary. 

Returning to inflammation : — it is clear that its most essential 
element is the presence of an unusual quantity of blood in a part ; 
and it may be thought that it would be an improvement on taking 
blood from the general mass, if the blood were taken from, or as 
near as might be from, the part affected. We see indeed something 
in the phenomena of local bleeding which inclines us to think that 
this is the case. A given quantity of blood taken from the part, or 
its immediate vicinity, has a much greater effect in subduing inflam- 
matory action than the same quantity, or indeed commonly a much 
larger, taken from the general system. 

Still, in serious inflammations, we dare not trust this mode of 
proceeding ; because experience shews, that if we take blood from 
the part, the same cause, whatever that is, continues to send in a 
new supply : and we are led to conclude, that, in severe inflam- 
mations, we can only combat this excessive action of the parts by 
reducing the pow'ers of the system altogether. But the more we 
consider the subject, the more distrustful we become in regard to 
the abstraction of blood (considered as such) being the thing re- 
quired : and the more we are led to refer its salutary operation, as 
regards its immediate effect on the inflammatory disturbance, to 
other circumstances, including that general reduction of the vital 
forces which it produces in common with many other modes of 
proceeding, — we perceive, also, that even when we do combat 
inflammation by the reduction of the powers of the system gene- 
rally, the reduction of powder, and not the mode by which it is 
accomplished, is the essential thing. The reasons are the follow- 
ing : in estimating the eff"eet produced on inflammatory action, by 
general depletion by blood-letting, we can in no case safely esta- 
blish any proportion between the quantity of blood abstracted and 
the efiect produced on the inflammation. Thus, in prescribing 
rules for bleeding in important and dangerous inflammations ; as 
those threatening the integrity of an organ, as the eye ; or those 
dangerous to life, as of the chest &c. ; we cannot direct the student 
or practitioner to draw tw^elve, twenty, thirty ounces of blood, nor 



311 



indeed any ottier quantity. We say that he must bleed to af- 
fect the system, and cause the patient to faint, or give other 
very unequivocal evidence of reduction of power. It is to be 
further observed, that this reduction of power is not sought even, 
only in relation to the quantity of blood ; but it equally regulates 
our manner of abstracting it. For we do not find that the effect 
on the inflammation bears any appreciable ratio to the quantity of 
blood abstracted, but to the depression induced by it ; and we avail 
ourselves of the circumstance in order to economize the depletion. 

When we endeavour to subdue inflammation by bleeding, we 
bleed in a manner which has for its object the induction of faint- 
ing, or of a state approaching to it, by the loss of the smallest 
quantity of blood : thus we bleed from a large orifice, because ex- 
perience has shewn that the rapid abstraction of a given quantity 
of blood depresses the actions of the system more than perhaps 
double the quantity would do were it drawn slowly, or at repeated 
bleedings. Hence it arises, that, when we do bleed, the mode 
which I shall recommend for this purpose, — though, in appearance, 
it be bold and severe, — is, in truth, that which most strictly econo- 
mizes the strength, and secures the safety of the system. As gene- 
ral bleeding acts on the increased actions of inflamed parts, by 
means of lowering the actions of the whole system, it is apparently 
paradoxical, that general and local bleeding, though they both ab- 
stract blood from the system, and, in many cases, both relieve 
inflammation, yet really appear to act on a different principle ; the 
general bleeding, by lowering the whole actions of the system, and 
consequently of the part itself; the local, by relieving or tempo- 
rarily removing a state of local congestion — a state which, though 
not the cause of inflammation, is a necessary element in its for- 
mation. 

Local bleeding, however, opposes congestion in a way which 
does not necessarily act on the circumstances which determine the 
blood thither : so we see why it can rarely, if ever, be trusted to 
in inflammation. Whereas, inflammation being essentially a vital 
process, no matter w^hat its nature may be, — and general blood- 
letting, carried to a certain point, reducing all vital processes, — we 
readily perceive why its effects should be very different from those 
of local bleeding ; since this is rarely (and, of course, it is only on 
this mode of its employment that I am speaking) carried to such 
an extent as to affect the constitution. When it is, then, necessa- 
rily, its effects become like those of general bleeding, instituted as 



312 



such ; but usually with a mu«h greater expenditure of blood. This 
is particularly exemplified in children. But to resume the question 
of blood-letting in inflammation, with a view to throw some light 
on the nature of that process. I say it appears to act by reducing 
the power of the system, and not by any specific mode attributable 
to the fluid as blood. This is further illustrated by the action of 
other remedies ; for, if we can reduce the actions of the system, 
we feel that it answers the purpose of blood-letting ; and that, in 
fact, if we can get parts to pour forth their secretions in a very 
copious manner, this is often equal to blood-letting. It might 
be objected that this is just as much a depletion as blood-letting : 
so, in truth, it may be in some cases ; but that it does not depend 
on the depletion, appears from any excessive evacuation being by 
no means an essential condition ; for, if we can depress the actions 
of the system, no depletion at all (reasonably to be regarded as 
such) is necessary. 

The action of tartrate of antimony, in all the phenomena which 
it presents, is highly instructive in this matter. In the first place, 
the action of tartrate of antimony, in reducing the action of the 
heart and arteries, is well known. The application of this power, 
in the treatment of inflammation, is equally incontestible ; and, 
what is more to the point, the abstraction of blood, no matter to 
what extent it be carried, by no means precludes the necessity of 
the use of tartrate of antimony, or other means adopted with a 
similar intention. I merely take the tartrate of antimony, in this 
enquiry, as a remedy most familiar and striking. On the other 
hand, tartrate of antimony will do without bleediug in many in- 
stances ; and although, where the tartrate of antimony is employed, 
it must be admitted that bleeding is also commonly practised, yet, 
in mo.ny cases, it is either not employed at all, or in such a mea- 
sured manner as not materially to obscure the effect which tartrate 
of antimony has in subduing the actions of the system, and, 
through them, the action of parts labouring under inflanmiation*. 
To resume our consideration of blood-letting in inflammation, as 
assisting us in the investigation of that process, let us discuss the 

* But this by no means conveys the real mode in which, after all, tartrate of 
antimony does ^ood ; since it is one thing to stop inflammation by subduction of 
power, and another to institute condirions which are calculated to direct that power 
aright. The determination to the surface, occasioned by tartrate of antimony, 
seems the essential thing. See " Treatment," and especially what is observed 
in regard to mercury. 



313 



manner, and, what is more to our purpose, the circumstances under 
which Nature may be said to bleed ; for, if blood-letting do not 
minister to the cause of inflammation, but operate indirectly, as it 
were, and therefore be a remedy which (as regards the real causes 
of inflammation") arises out of our ignorance of a better, rather 
than our knowledge of the true nature of the disease we en- 
deavour to relieve, — a contemplation of this remedy, when em- 
ployed by Nature, must do something w^ith the propositions implied 
in the foregoing enquiry ; that is, it must either tend to establish or 
overthrow them. 

Now, that a fluid, so elaborately made as is the blood, re(;[uiring 
such a vast apparatus in all animals for its production and distribu- 
tion, should be otherwise than economically managed by Nature, 
is contrary to all analogy. Because, in all parts essential to vitality, 
it is the habit of Nature, if I may so say, to guard them with pecu- 
liar care ; and hence copious, spontaneous discharges of a fluid, 
like the blood, is certainly one which, suppose we had no experience 
on the subject, we should, a priori, not be disposed to anticipate. 

When, therefore, we find that Nature does create, somehow or 
other, a discharge of blood from the system, — and that, too, in 
some cases, in considerable quantity, and not as a process natural 
to the healthy oeconomy, as in the case of the menstrual fluid, but 
evidently as an occasional supervention on and with relief to a 
disease, — ^it is obviously necessary to examine how far it is a natu- 
ral remedy, in the true sense of the word, and how far it is one to 
which Nature is driven, not so demonstrably perhaps, but scarcely 
less certainly, than when one of the vessels by which she distri- 
butes the blood is opened by mechanical division. 

Now, if blood-letting be calculated to assist us in removing 
disease, it is evidently a remedy requiring much discretion in its 
employment ; for it is revolting to common sense to suppose that 
the abstraction of this fluid can be (in any quantity as to aff'ect the 
system) a matter of indifference ; yet it is not exceeding the 
truth to say, that no remedy has ever been employed with less dis- 
cretion, nor any measure contributed more to lull investigation, or 
to obscure enquiry into the real nature of disease. Men practising 
under traditional or conventional authority (the idols of the market- 
place and theatre of Lord Bacon) have contentedly employed a 
remedy which appeared to relieve symptoms ; and, in case of fai- 
lure, have as readily attributed it to causes which our ignorance 
could not penetrate, or as an exception to a general rule : and in 



314 



the continuance of this error, the subject which we are now about 
to examine, — namely, the fact of Nature herself occasionally bleed- 
ing, — has perhaps greatly contributed ; whereas, carefully examined, 
it will be found not only to impress us with that discretion in its 
employment which growing experience never fails to produce, but 
may assure us also, that just as we employ it in inflammation, so 
Nature uses it to relieve symptoms where she is demonstrably pre- 
vented by adopting that which would really be her own mode ; 
viz. removing the cause. 

Now what are the phenomena presented to us in spontaneous 
discharges of blood ? and, in considering these, we will take the 
most common examples ; because facts should be trite, if people are 
to reason together. I presume, as admitted, that the most frequent 
examples are presented in bleeding from the nose, and from the 
vessels of the rectum in hsemorrhoids. 

In the first place, the blood is discharged in moderate quanti- 
ties ; for, although the aggregate quantity is often very consider- 
able, yet it is generally discharged in small quantities at a time. 
There is no estimating the absolute amount in those who are 
habitually subject to bleeding from haemorrhoids ; but it must be, 
in some cases, very great in the course of a certain number of days 
or weeks. 

It is true also that, in some cases in which the causes are 
allowed to operate altogether unconti'olled, the discharge of blood, 
both from the rectum and from the nose, is very profuse ; so co- 
pious, indeed, as sometimes to threaten, and in rare instances to 
destroy, life : I have seen this happen in bleeding from the nose. 
I was sent for to a man who laboured under this complaint (tech- 
nichally termed epistaxis), whom I found in the last stage of ex- 
haustion : the haemorrhage had indeed ceased when I saw him ; 
and, notwithstanding that its recurrence was prevented by plugging* 
the nose, as it is termed, yet he did not recover. 

The same results have been said (though still more rarely) to 
follow bleeding from haemorrhoids ; but of this I have never met 
an example. Notwithstanding, however, for one cause of fatal 
haemorrhage from such sources, thousands — perhaps I should 
scarcely exceed the truth if I said millions — occur in the way I 



* Passing a cylinder of lint sufficiently large to occupy the passage along the 
floor of the nostrils, as far back as the palate, by means of a probe. 



315 



first mentioned ; tliat is, in small quantities— and often, let me add, 
with marked relief to some sensation of disorder. 

But let us examine the eases; and, first, let us discuss the 
case of haemorrhoids or piles ; because, whilst the case is common 
and known to all, no one has perhaps led to more erroneous con- 
clusions ; since, of the mischiefs so commonly known to result 
from the stoppage or sudden cessation of natural haemorrhages, no 
one class of cases has furnished more numerous examples. 

We are here struck with the analogies afforded by the bleeding 
from piles with those presented in the practice of blood-leltin g, 
in that, although both relieve symptoms and parry danger, yet 
neither one nor the other administers to the real cause of the dis- 
ease. Piles are always connected with either a local or general 
plethora ; and we will first take a case where the falness may be 
regarded as local, and seated in the liver — a most undoubted cause 
of turgescence of vessels and haemorrhoids in the rectum. Now, 
when we see how the great vein of the liver (vena portae) is 
formed, we immediately perceive how bleeding from the rectum 
must necessarily relieve the circulation of the liver ; but it is 
equally clear that it does not strike at the root or real pabulum of 
the evil ; since, although it diminishes the turgescence, it does not 
minister to the cause of that turgescence, but only to its mechanical 
diminution when once it has been induced. 

When we inquire into the causes, we find ourselves unavoid- 
ably driven to consider all those which disturb the oeconomy of 
the liver, whether as regards the quantity or quality of its blood, 
or those which act, in some way or other, sympathetically to dis- 
turb its functions. We know these to be, full or improper diet, 
luxurious living, indolent habits, want of exercise, moral causes, 
and other conditions of certain organs, with which the liver may 
hold especial sympathetic or mechanical relations, as the head or 
heart, for example. 

That these are the real causes, experience very impressively 
teaches us ; for, whilst no bleeding, either natural or artificial (a 
mode much used on the Continent), from the rectum, will prevent 
the recurrence either of the piles or the bleeding, cautious diet, 
exercise, regular bowels, and in short the removal of the various 
causes, will do both, as I have known in a number of instances ; 
whilst, where the heart is diseased, the piles remain, because we 
cannot cure certain conditions of that organ. We know also that 
a general fulness of the system is exceedingly prone to produce 



316 

fulness of the liver, and that piles are the frequent result ; but, in 
this, as in other cases of the same kind, if we seek to relieve the 
piles, as we are often called on to do, as they produce occasionally 
great suffering, we direct poultices, recommend the horizontal posi- 
tion, &c. ; but, if we aim at the prevention of their recurrence, we 
must subjoin other measures. We must prohibit excesses of all 
kinds, enjoin abstinence from fermented liquors, recommend exer- 
cise, regulated temperature ; in short, a preventive plan, such as 
common sense and experience alike shew to be effectual in promot- 
ing and maintaining an improved condition of the general health. 

We learn that, with the sustained observance of these measures, 
patients remain \vell, and that, in their absence, all other measures 
are but palliatives ; that either the disease returns, or that maladies 
still more protracted and dangerous are substituted for them. 
Why Nature does not institute these remedies is also clear ; because 
we put it out of her powder : and, in so doing, it is to be observed 
that the inclinations or appetites of the patient are scarcely more 
influential than are the erroneous applications of (so called) me- 
dical science. 

These are the arguments severally used on such occasions. If 
people are warned by pain, oh ! they must eat, to support their 
strength ; if the suggestions of Nature consist of loss of appetite, 
nausea, or sickness, the tone of the stomach must be maintained 
by tonics and tilings of that kind. x\n active dose of calomel, to 
emulge the liver, aperients for the bowels, and columba, gentian, 
bark, or something of that class, for the stomach, are the ordinary 
exhibitions of science : a few days' starvation may perhaps some- 
times be superadded. These privations, grievous as they are con- 
sidered, are perhaps regarded by the patient as far preferable to 
habitual moderation ; and the amendment, though not permanent, 
is rapid : and thus, unfortunately, whilst it is more acceptable to 
the patient, it is, to say the least of it, regarded quite as creditable, 
and generally more so, to the character of his medical attendant. 
Nature, therefore, finding her hints disregarded, which are gene- 
rally given by the stomach, ever abundant in resources, sets to work 
in another way, and generally by the next best ; that is, the evacua- 
tion of blood by the most direct channel ; for, if unwillingness to 
make more supply, as manifested by the stomach, be artificially 
stimulated into activity, if, in short, she be forced to make fresh 
supplies, it is obvious there are but few safe modes of getting rid 
of them ; and a very direct mode is the one in question. 



317 



Even in cases where it becomes expedient to remove diseased 
growths, all of which will be more fully discussed at the proper time, 
we see the real causes of these maladies, and the necessity of admi- 
nistering to tliem, if we are to obtain permanent relief for the pa- 
tient. Take the following case as an example : A lady had been 
suffering for seven years from that form of piles in which occa- 
sional bleeding had been followed by repeated descents of small 
portions of the lower bowel, which, in the course of time, had un- 
dergone change of structure, many of them having become covered 
with cuticle : she had had a great deal of advice and medicine, and 
with temporary benefit ; but she had continued to get worse and 
worse ; so that, as happens in severe cases of this kind, she had 
not been able to sit dow^n for a long time without some provision to 
avoid pressure ; and even with this provision she would often suf- 
fer great pain. As somebody told her nothing would relieve her 
but an operation, she sent for me ; and at this time there was a 
congeries of heemorrhoidal tumours, about as large as an orange : 
they often bled profusely, and were exquisitely tender. The mo- 
ment I saw her, it was evidently absurd to expect any permanent 
good from an operation in her present condition. She had scarcely 
any function going rightly ; her liver was especially out of order ; 
and her general aspect exhibited a yellow paleness more character- 
istic of a person with dropsy from diseased liver than any thing 
else. I therefore began to regulate her liver, her bow^els, and to 
act on her skin. She had daily enemata of warm water, and a 
spare and simple diet. Under these measures, the tumours began 
sensibly to diminish, until at length the operation, which, at an 
earlier period, would have involved the removal of a large, irre- 
gular tumour and considerable suffering, was really, when undertaken, 
a mere nothing, — a couple of strokes of a common pair of scissors 
being all that was necessary and even this ; I verily believe, might 
have been avoided by continued perseverance in the measures she 
was employing ; but, as I wished her, above all things, to get exer- 
cise as soon as she could, I removed the parts so diminished ; and 
she has remained perfectly well, though, on one occasion on which I 
saw her afterwards, she was beginning to relax as to the observance 
of regular exercise. 

I have known many cases of a similar kind, and of many 
years' longer duration : but I will not interrupt the thread of our 
argument by the relation of them in this place. I have also known 



318 



these tumours removed without the required precautions, and soon 
followed bj other diseases. 

Now, if we apply the foregoing observations to our mode of 
bleeding, we are immediately struck with the parallel, I should say 
the identity, of the two cases, as regards their essential principles. 
There is, however, this remarkable difference — that we bleed be- 
cause we are contentedly ignorant of any other mode of relieving 
the symptoms ; whilst Nature does it because impediments are 
thrown in the way of her more effectual and salutary operations. 
What I have been here applying to a plethoric state of a particular 
organ (the liver), equally applies to spontaneous bleeding, where it 
appears the result of general fulness. The real cause is here the 
regulation of the supply of blood to the system : but here again 
bleeding, cupping, and temporary abstinence, are preferred to habi- 
tual moderation ; and, what is worth remarking en passant, disor- 
ders are frequently engendered which may well be amongst the 
most puzzling, since they consist of certain tortured conditions of 
the oeconomy, the offspring of art, and therefore can be referred 
(only through an immense increase of difficulty and obscurity) to 
the laws or operations of Nature : wliilst thus treated, the body 
often gets into a state where bleeding, natural or artificial, becomes 
perhaps, in the end, the only remedy. 

Organs, constantly disturbed in their functions, at length be- 
come diseased. The liver or heart, for example, becomes clianged 
in its structure. The former, from being, in a healthy state, the 
largest organ in the body, may become so changed, that perhaps 
but a small portion of it may retain its natural character and 
powers. The heart, most admirably constructed for a function very 
complex in its natural character, has its mechanism interfered with : 
its power becomes too great ; the blood is circulated with too great 
a momentum, or it becomes diminished, it can no longer impel 
the blood with the required force, and then the circulation either 
fails in the extreme parts, or it is effected only by alternations of 
violent, unnatural excitement, with conditions of torpor or inaction. 
Besides its power, its mechanical apparatus becomes disordered : 
its valves become thickened, they act imperfectly ; it is out of 
order as an hydraulic instrument ; and thus we have the elements of 
continual disturbance : and now we have increased susceptibilities 
to disorder, this susceptibility allowing disorder to be excited by 
very trifling causes. 



319 



The means so neglected, once so efficient, now prove only pal- 
liative ; that moderation which, to a sensible man, scarcely implied 
any rational sacrifice, is now not only essential, but is converted 
into habitual abstinence ; and even this will not ensure (in the 
deranged condition of the respective organs) any certain or durable 
immunity from disturbance. Even the food necessary to the sup- 
port of life becomes inconsistent with comfort ; and now indeed we 
are reduced to palliatives from necessity ; since, in the present 
state of science, we know of no means of curing organic disease in 
organs the continued function of which is absolutely essential to 
life. It is true indeed, that, in this lamentable state of things, with 
unavailing regret at the past neglect, we still see types of the effi- 
cacy of that treatment which rests on endeavours to relieve a 
labouring organ from its functions, in that those endeavours are 
still the best we can adopt ; but we are obliged, now that the 
power becomes so limited, to take blood occasionally perhaps, or 
look with satisfaction to the same remedy as the occasional effort of 
Nature ; because, so diminished is the power, so destroyed the 
equilibrium between the powers of the stomach and other organs, 
that all practicable diminution of supply will not obviate the ne- 
cessity of occasionally relieving the circulation by direct abstraction 
of blood. 

I shall not enter much into the history of bleeding from the 
nose, another frequent example of heemorrhage ; because, mutatis 
mutandis, the cases are the same. Bleeding from the nose may occur 
from causes primarily affecting the head or other parts, as the sto- 
mach, liver, &c. ; but in these cases the real cause is the disorder 
which determines this bleeding, — the real cure, its removal. There 
was lately a case in the Dispensary, where bleeding from the nose 
occurred in connection with determination of blood to the head, and 
with other symptoms of partial circulation. The man's nose was 
plugged, but the plug only remained a day. Measures however 
were instituted to equalize the circulation ; especially, in this case, 
the use of the steam bath ; and no bleeding recurred, notwithstand- 
ing that it had frequently happened before. The congestion in the 
cerebral circulation, for the relief of which this natural bleeding is 
commonly instituted, may be relieved by it : but here again we 
see, by reasoning, and, what is to the point, we have it confirmed 
by experience, that the bleeding only ministers to a symptom ; the 
real cause of the disease is left untouched ; that being whatever 
caused the determination of the blood to the head. Nor does it 



320 



alter the argument one iota, if we suppose the cause to be one 
which possibly is not uncommon, — viz. where the haemorrhage 
takes place from direct sympathy of the mucous membrane of the 
nose* with the continuous surface of the alimentary canal, or some 
other part, without any intervening disturbance of the cerebral cir- 
culation, integrally considered; for the cause is evidently that 
circumstance, whatever it is, which produced the disturbance in the 
organ which the bleeding from the nose is instituted to relieve. 

Natural bleeding may of course take place from any surface, in 
consequence of lesion of that surface ; but this is a different thing. 
These cases carry with them their own explanation. But as all 
processes of Nature, whether resulting from accident or otherwise, 
generally evince uniformity of plan ; so the occurrences which are 
observable when an artery is divided by accident, present certain 
tj-pes of that sustained tendency in the oeconomy to save the 
blood. 

^Yhen we consider the heart, with reference to its mechanical 
power, and the hydraulic relations which are established between it 
and the vessels, as essential to the freedom of the circulation, one 
would certainly, without experience, be inclined to believe that the 
actual di^■ision of an artery would necessarily be fatal ; for, with an 
open vessel at one end, and a powerful pump at the other, one sees 
no reason, a priori, why the bleeding should not indefinitely con- 
tinue : but we find that this is by no means the case, and that, in 
fact, for this fatal result, a number of conditions are necessary, 
which are not always combined when arteries have been intention- 
ally divided ; and, what is still more interesting, much less frequently 
where they have been injured by accident. When diseases of ar- 
teries are considered, these circumstances must be particularly 
described. But I may observe, even here, that the timely faintness, 
the contraction of the artery, and the coagulating tendency of the 
blood, are all circumstances calculated to restrain haemorrhage 
under circumstances where it would seem unavoidable. The scien- 
tific or professional reader will see how readily this argument 
might be extended; but I have perhaps said enough to shew 
that the true light in wliich we should regard spontaneoiis dis- 
charges of blood, is, that it is a remedy to which Nature may be 
said to be driven, rather than as adopting, in the free exercise of 
the preser\^ative powers of the animal oeconomy : that, like other 



• See Sympathy. 



321 



remedies adopted hy Nature, though it is the least injurious per- 
haps in the particular cases, jet it is only so because the proper 
mode of relief is prevented hy injurious agencies, superinduced on 
her operations by ignorance, art, or inclination, as the case may 
be : but that, inasmuch as it does not minister to the real cause of 
the disease, so is it not successful ; that it is at best a palliative, and 
even, in some cases, a disease scarcely less formidable than that 
which it tends to relieve ; all of which would be inconsistent with 
the laws of Nature, were it not probable that it is a remedy adopted 
under circumstances of restraint or coercion. We farther learn, 
however, that notwithstanding that occasional examples of the last 
remark do undoubtedly occur, yet, in the vast majority of cases, 
it is adopted with apparent caution, or, at all events, with a 
practical oeconomy of the expenditure of blood. We find, from 
other sources too than natural bleeding, that loss of blood is a costly 
remedy ; and every day's experience is enforcing, very impressively, 
this conviction. 

We know now that large abstractions of blood, though their 
effects are not always immediate, often seriously influence the 
future conduct of the circulation ; and I cannot help thinking that 
we are progressing towards a very important discovery on this 
subject, not only as regards its bearings on inflammation, but on 
the treatment of diseases in general. 

In relation to the diff"erent modes in which local bleeding acts, 
I would remark that suggestions, arising out of the consideration of 
hydraulics, seem to offer some explanation of the greater benefit 
arising from the abstraction of small quantities of blood drawn 
from or near the inflamed part, as compared with those arising 
from tJie same quantity/ drawn from the system at large. If I open 
a certain number of vessels on the skin covering the side or the 
site of an inflamed part practically, I determine the blood to the 
particular tubes on the surface. To effect this, however, I must 
somehow or other increase the size of those vessels, or the mo- 
mentum of the blood moving in them. Now, that opening them 
has no tendency to increase their size, is clear ; therefore we 
must examine whether we increase the momentum of their con- 
tents. This can only be done by increasing the power of the 
heart in regard to these particular vessels, which, in a direct sense, 
is obviously impossible : or, the power of the heart being the same, 
we must lessen the resistance in those particular vessels ; which, 
practically, is the same thing. Now this, I conceive, we actually 

Y 



^22 



do when we open the vessels bj leeches, or in any other way : that 
blood which first flows out of the vessels meets with less resistance 
than it does whilst in the vessels whence it flows ; and the blood 
will, on hydraulic principles, go where it meets with least resist- 
ance ; and thus 1 practically determine blood to the vessels so 
opened. Indeed, inflammation itself implies the presence of a si- 
milar principle ; since, whether we regard its primary condition as 
an increased action of the arteries or their contents, or as an en- 
largement of those vessels, they alike aflbrd hydraulic facilities to 
the egress of blood into the part, — the essence, in fact, of that con- 
gestion, more or less of which is necessary in all inflammation 
whatever. 

From the foregoing observations, it appears that we cannot 
look for the real cause of inflammation in the part inflamed ; 
that although congestion of blood in the part is an essential ele- 
ment in inflammation, — and that though determination of blood to 
a part is a necessary condition to such congestion, — yet both one 
and the other are parts of, and not causes of, the inflammation : 
the real cause being that which determines the blood to particular 
parts, in the first place, and which further determines that the use 
to which such blood is converted, or the sequence of each determi- 
nation, is to be the production of inflammation. I have already 
shewn that there is an obvious tendency to determine various 
actions, which we call disease, to the surface of the body ; that in- 
flammations of various and apparently of very dissimilar charac- 
ter have their seats at or near the surface ; and that, in a variety of 
them, and those too most frequent and familiar, the effect is, in the 
main, demonstrably an effort to relieve the system of something 
w^hich disturbs the animal oeconomy. 

We farther infer its salutary tendency to be most safely ex- 
ercised, as it occurs on the surface, from what we know when it 
attacks various organs more deeply seated ; inflammation in such 
cases always proving highly dangerous ; and unless the organ be 
previously, to appearance, sound, thatis, not obviously changed in 
structure, it is almost invariably fatal. I believe that I am here 
stating the general conviction of the profession ; but certain it is, 
that it is emphatically my own. I always regard inflammation in 
an organ, previously known or suspected to be changed in struc- 
ture, to be in the highest degree dangerous, and, in fact, always 
justifying a v^ery unfavorable prognostication. The patient can 
neither bear the mflammation nor that reduction of power usually 



323 



involved in all the present modes of opposing it : and I am so confi- 
dent on this point, that I have foretold the consequences of such an 
attack where I knew an organ to be enlarged, although the pre- 
sence of apparently the most perfect health was calculated to lull 
suspicion, and that vigilant caution on the part of the patient 
which it was the object of the opinion above stated to rouse and 
sustain. Of all cases these are the most important in reference to 
improved modes of combating inflammation. (See Treatment.) 

The danger of inflammation in internal organs must always 
be great ; since one of the invariable efl'ects of it is to suspend or 
to embarrass the function of the part in which it is seated. Now 
we cannot suspend the functions of vital organs, nor, indeed, im- 
pede or embarrass them for other than a very short time ; whereas, 
those of the skin, cellular tissue, and even the mucous lining of vari- 
ous canals, can be embarrassed or suspended, not without great suf- 
fering truly, but, as we practically find, with comparative impunity. 
In speaking of the skin, however, I only mean parts or districts of 
it ; for no organ can be less safely embarrassed as a whole than it, 
as severe burns impressively teach us : but then we never see it 
wholly inflamed : the only case we have approaching in its effects 
to this state of things, occurs in fever, which is a striking illustra- 
tion of the foregoing observation. Fever does, it is true, some- 
times terminate in inflammation near the surface ; but then it is 
always partial, the result being inflammation and abscess of some 
particular district ; the parts involved being skin and its elastic 
substratum, the cellular tissue, as in abscesses following fever : the 
parts being usually afl'ected on the inverse order in which I have 
mentioned them. 

We now, then, are to consider what it is in inflammation that 
determines the blood, and the actions consequent on such a deter- 
mination, to this or that district. We have seen that, in gout, 
scrofula, rheumatism, erysipelas, boil, and carbuncle, there is an 
evident disorder of the system ; and therefore we assume, that if 
this disorder cause these particular kinds of inflammation, there is 
no reason, to say the least of it, why it, or some other disorder of 
the system, should not give rise to any other variety. 

In relation to this assumption, as apparently not the direct 
result of induction, it should be borne in mind that similar local 
processes result from apparently different causes in the animal 
oeconomy, where the real cause is the same : for, in regard to the 
law of inflammation, the question is, not what substance deranges 



324 



the animal oeconomy, or what organ disturbs it, so much as, is the 
ceconomj disturbed ? When the ceconomj is disturbed bj alcohol, 
or gorging the stomach, or by opium, in certain cases, — though the 
agent be different, the manifestations are the same ; — on the con- 
trary, the same injurious agent will produce different manifestations 
of disturbance. Thus, ipecacuanha will purge in one case, vomit 
in another, induce perspiration in a third, depress the heart in a 
fourth, and all of these in a fifth case. But in all these cases the 
results have one thing in common, — viz. the disturbance of the 
ceconomy. Now, in regard to local inflammations already men- 
tioned, the peculiar cause may be different ; so its peculiar local 
demonstrations: but they both have this in common, — viz. ge- 
neral disturbance and local disturbance, — that disturbance being 
inflammation. 

I say, then, we assume the foregoing for the moment, in regard 
to any variety of inflammation, because it is the most reasonable 
assumption : other grounds on which it is founded we shall ex- 
amine presently. As a primary assumption, we must either refer 
common inflammation, as it is called, to the influence of the same 
general laws, or we must assume that it results from difi*erent laws. 
Novr, to do this would at least be contrary to analogy ; for what 
have we been doing in the catalogue of inflammations already pre- 
sented ? — why nothing else than reviewing all the visible inflam- 
mations with which observation has furnished mankind, that which 
is called pure inflammation only excepted. This is strictly true ; 
because, although we certainly do meet with inflammatory dis- 
turbances which we cannot call either gout, carbuncle, boil, erysi- 
pelas, &c., yet we never find any difliculty in referring it to one or 
other of these several examples of inflammatory action. Language 
is very inadequate to express various shades and alterations of dis- 
ease, as it is to express every kind of idea ; as Sir James M'Intosh 
said in regard to philosophical disquisitions generally ; so, in regard 
to disease, we work on a very delicate subject with very coarse 
tools,'' or words to that efteet. In diseases, we find every variety 
with which we are acquainted gradually shaded off into the next 
cognizable o]' marked link in the chain of its relations ; and we 
are onlj- able to designate the more obvious varieties. To give a 
disease a name, is, in fact, very often impossible ; although it is to 
be feared that the public frequently attach great confidence to those 
who have tact enough to make one on the moment ; which reminds 
me of a story at the Hospital, concerning a pupil who, bothered 



325 



by a woman to say what her disease was called, said it was a 
" cacoethes loquendi," with which the woman seemed highly 
delighted. 

Should we then he disposed to consider that purer inflamma- 
tion, which unquestionably afl'ords the best proofs of the powers of 
Nature, as an exception to the laws which prevail so extensively 
in the animal oeconomy, and which are so plainly accompanied 
by phenomena of a preservative character, — this, if it be nothing 
else, would be arguing, so far as our knowledge goes, on the ex- 
ception, and not the rule ; and would be, at all events, referring 
phenomena very analogous to different laws from those to which 
we had traced other inflammations, merely because our ignorance 
did not allow us safely to refer it to the same law^s : it would be 
preferring an assumption entirely gratuitous, to one supported at 
least by all the argument deducible from a striking analogy : but 
right is not necessarily the reverse of wrong. It would be better 
not to conclude any thing, than to determine that the laws must be 
different, solely because we could not demonstrate their identity. 

So much for what might be assumed a priori ; but I contend 
that the reference of common inflammations to the same general 
laws, is, in the highest degree, probable. It is philosophical in its 
primary assumption, and it is all but demonstrable on the true 
principles of induction ; at least, I see no other mode of getting 
rid of the facts which I am about to mention. I beg to remind 
you, however, in this place, of the definition I gave you of what we 
call common or pure inflammations ; whilst I declare to you that 
they are of extremely rare occurrence ; and, in crowded cities, 
scarcely ever seen, except after injuries wherein their preservative 
actions are as demonstrable as the properties of a circle, or any 
known problem in mathematics. In wounds in a healthy person, 
whether made intentionally or by accident, w^e have examples of 
pure inflammation ; and, in every case, with perfect success : for, 
as the inflammation is moderate in degree, and in as much as it 
is free from any of the characters accompanying the other inflam- 
mations of which I have spoken, so are repairing processes rapid 
and progressive ; nor is this process to be regarded as a diseased 
superposition occasioned by the injury: it is evidently a necessary 
excitement, from the simple fact, that no one ever saw a part re- 
paired without it ; hence, that all parts should possess powders of 
Repair, it is necessary that all parts should have the power of in- 
flammation. 



.326 



The ordinary powers of the part are emploj'ed in the mainte- 
nance of its structure and functions, including growth in the young 
subject ; but to these are added the duty of repair ; and, as the 
agenda are thus increased, the actions are increased also. If we 
wanted any furtherance to our con^nction of this, beyond that af- 
forded by the beautiful process of repair, without a shade of pain 
or an interval of interruption, we find it in this fact, that, if fearing 
the excitement should be excessive, and the inflammation should ter- 
minate in some other process than the one required, — I say, if fearing 
this, — we are too assiduous in subduing the actions of the part ; 
we do any thing but promote the cure ; we depress the necessary 
actions : and we retard, or altogether suspend, the necessary re- 
pair. So much then as regards the peculiar character of pure in- 
flammation, in the purest cases we have of the process : but I say 
again that such cases of pure inflammation are extremely rare ; 
there is not one inflammation in a thousand — that after injuries 
excepted — which does not present some obvious departure from 
what we define as pure inflammation, and which is not accompa- 
nied by characters which decidedly link it with one of those which 
are demonstrably but indications of disorder of some part or of the 
whole animal oeconomy. Supposing, then, that such examples of 
pure inflammation do really occur on the surface of the body with- 
out cognizable disorder, or in internal parts which, from their phy- 
sical characters being concealed, we cannot, from such evidence, 
pronounce to be of the impure kind, sliall we infer, therefore, that 
no disorder exists ? The very idea to me appears monstrous. 

I need not repeat the arguments derived from the difi"used in- 
flammation of the serous membranes ; and, for more practical 
proofs, I refer you to the section on Treatment. 

\Yith regard to inflammations, occurring in parts not visible, we 
have only to consider the phenomena and the circimastances under 
which they are developed ; and we shall then be prepared to con- 
sider the laws to which they may be referred, I take it for granted 
that they occur in virtue of some law or other ; that this is an ad- 
mitted truism : wherefore the business will be, to investigate how 
far they fall under the laws I have mentioned, or what are the in- 
terfering influences which appear to render the phenomena which 
they exhibit as exceptions to such laws. A man, apparently in 
health, gets wet in his feet, is exposed to wet and cold, and he 
has inflammation of the bladder or chest. I here mention this 
most common precursor as regards the chest, and the most common 



327 



example of inflammation. Now here we have an inflammation 
affecting either the lining of the ramifications of the wind pipe, the 
substance of the lungs, or the membranes which cover them. In 
the abdomen, we have either the mucous lining of the bowels, or 
the external covering, a continuation of which also lines the walls 
of the abdomen inflamed. I have told you before that, in general, 
it is one of these external surfaces which is most commonly affected ; 
and have remarked, also, that the internal surface of these viscera 
is absolutely continuous with the surface of the body. 

Now inflammation, we will say of the pleura, takes place ; and 
the question is, how it has happened. Many questions occur here 
which may be difficult of solution; but they must be considered, 
if we wish to understand the real nature of the case. That the 
application of cold and moisture is not the sole cause is clear, be- 
cause we find these agents are often applied without any such 
effect, and that, not only in other individuals, but in the individual 
who is the subject of inflammation ; and yet that the application of 
these agents had something to do with the matter is equally indis- 
putable, because the influence of such agents, and inflammation as 
sequences on them, are daily occurrences : and this, from the vast 
multitude of such cases, has become as familiarly known to man- 
kind in general as it is to the profession. 

If, therefore, the same causes have acted on the same individual 
on various occasions without injury, and now produce inflamma- 
tion, it is clear that, if the causes be the same, the body on which 
they operate must be different ; otherwise, effects so strikingly 
different would not follow. 

On enquiry, in many instances, we find this difference so well 
marked as to be demonstrable : the existence of a difference, and 
the demonstration of its nature, are of course separate proposi- 
tions. We find, for example, that, if any of the organs of the 
body be previously out of order, exposure to cold and moisture is 
especially dangerous, and particularly perhaps if there be any dis- 
order of the lungs or of the digestive organs. We find also that, 
if the disorder involve any change of the structure of any organ, 
not only are cold and moisture very dangerous, but the attack will 
be probably in the organ so changed. Thus, if a man have dis- 
order or disease of his lungs or liver, and catch cold, we may pre- 
dict, with considerable certainty, that any inflammatory disturb- 
ance, occasioned by the cold, or arising as a sequifur on it, will be 
seated in the organ in question, or on its investing membrane. 



328 



The reason of tliis I have already endeavoured to explain in 
the book I have already referred to on the Sympathies of the Body, 
&c. ; and that it arises from the general sympathy of all parts of 
the body with each other ; and from that increased susceptibility in 
which diseased or disordered organs have to sympathize with any 
powerful impression made on any other organ, and with the skin, 
in a very remarkable degree. The same reasoning, also, goes far 
to explain why one organ becomes the seat of inflammatory dis- 
turbance in one case, and another organ in another, since an 
increased susceptibility is the thing essential ; and this demonstrably 
depends, in many cases, on a previously disordered condition of 
the organ. 

Nor do natural peculiarities, idiosyncrasies as they are called, 
materially alter the question ; for it matters not how the disorder 
arises, as long as its existence is certain : and many individuals, 
who have diseased lungs, and in whom cold andmoisture, applied to 
the skin, affect the lungs, do, nevertheless, in the absence of any 
such impressions, evince phenomena ; shewing that, whether natural 
or acquired, the lungs are not in equilibrium with the other organs 
of the body. Therefore, it matters not, so long as there be sus- 
ceptibility to disorder, whether we can, in all instances, explain the 
reason, as in the existence of previous disease ; or whether it be so 
unknown as to be derived from parents, change of climate, or fall 
under the term idiosj-ncrasy. But now comes the question why 
the inflammation is not referred to the surface of the body, in con- 
formity with what I have endeavoured to enunciate as the law of 
inflammation ? In other words, what is the interference with this 
law ? and this I think very explicable. 

I have observed before, that every natural law, to be healthfully 
exemplified, implies the condition of natural power* : in other 
words, that the vital powers are not interfered with in their opera- 
tions. Now it is obvious that nothing interferes with this so cer- 
tainly as the system being previously disturbed. We can no more 



* Any natural law may be interfered ^^-ith, just as elasticity- may he obscured 
by pressure. Digestion is a law, as regards the stomach ; and it implies natural 
power. Muscles have certain laws; but these ngain imply natural power. It is a 
law that ycung animals grow ; but this requires natural power, or the growth 
stops : and so on of every part or every process in the oeconomy. Therefore it is 
quite consistent that any disturbance of the ceconomy should disturb any law, and 
that in various vrays ; modifying it, suspending or altogether preventing its 7na)it- 
festatian. 



329 



expect the liumau body to perform tlie mov^ements which are em- 
phaticallj illustrative of its perfect, because its most preservative, 
power, if there be disorder of some particular organ, any more 
than, as I have before observed, we can expect a watch to perform 
correctly, merely because its disorder did not entirely stop it. 
There is, then, a very competent explanation of the absence of a 
healthy development of the law which determines inflammation to 
the surface, in the previous disturbance of that equilibrium of 
function on which the manifestation of any completely healthy pro- 
cess essentially depends; but, besides this, another very potent 
cause why the inflammation should not be referred to the surface, 
presents itself in the facts which arise partly out of the individual 
condition of the particular organ attacked by inflammation, and 
partly from the necessary result which immediately takes place on 
the application of cold and moisture. 

We know that the immediate effect of cold and moisture applied 
to the skin is reaction ; that is, a glow, as it is temied : there is a 
resistance, in fact, to the tendency which these agents produce, to 
a departure of the blood from the surface ; and the increased diffi- 
culty of maintaining the circulation at the surface is met by 
increased action of the vessels ; but we know that, if the depres- 
sing influence of these agents continue, an opposite state occurs ; 
that paleness of the skin, with the sensation of cold, supervenes ; 
the blood actually circulates in less quantity at the surface. This 
blood must go somewhere, or it must be carried off by some secre- 
tion ; which we know does not necessarily happen. 

Now, if the body be perfectly healthy, we know that although 
for a time an increased quantity of blood must necessarily circu- 
late in the interior of the body, yet that, when the depressing influ- 
ence ceases, reaction takes place at the surface, and the equilibrium 
is restored. Two circumstances contribute obviously to this resto- 
ration to equilibrium ; the one, that, the organs being healthy, the 
vital powers are uninterrupted in carrying out the natural tendency 
to reaction ; and the other, that, the organs being healthy again, 
there is nothing to prevent that determination of blood to the inte- 
rior, consequent on the depression of its circulation of blood at the 
surface, from being equally distributed, so that eacli organ has only 
to provide for its due share of increase ; but, if there be increased 
excitabihty to disorder, and still more if there be previous disease, 
all this happy arrangement is reversed. Organs, either disordered 
in their functions, or diseased in their structure, become exceed- 



330 



iiigly excitable ; determinations of blood to them are at all times 
dangerous ; and tlins, wliile tliey are less able to withstand any 
sudden increase to the circulation, the excitement it produces tends 
to increase the quantity, and thus to aggravate the mischief. 

The fault here is not in the laws of the animal oeconomy, but 
in the previous disorder or disease which prevents these laws being 
carried out, by the disturbance of equilibrium. Congestion takes 
place in the organ ; and thus the essential, primary element of 
inflammation occurs, and with too frequent and certain develop- 
ment, in a part whose vital powers are previously impaired, 
in which, in fact, there is practically less life. The organ 
inflames, and, in by far the greater number of cases, exhibits 
still the tendency of inflammatory action, by establishing it 
at one or other of its external surfaces. But it may be asked 
again, why does it not refer to the surface of the body at once, as 
this would be the really safe habitat for inflammation ? One rea- 
son is plain, as already mentioned ; because that would be an exhi- 
bition of natural power which the organ has not : besides which, 
the skin itself is labouring under a depression of its vital powers. 
It is obviously unequal to that reaction which is essential to a re- 
storation of equilibrium : a fortiori, therefore, it is unequal to the 
still further excitement necessary to inflammation. That this would 
be the case, were it not for want of power to overcome the depres- 
sion, seems probable, from the fact, that occasionally we actually 
see the restoration to equilibrium after depression by cold, accom- 
panied by the development of inflammation in some part of the 
continuous surface. In considering, however, the want or absence 
of this power in the surface, we must not merely, in all cases, re- 
gard it as due solelj- to the depression occasioned by the cold ; for, 
if any organ, from the reasons before stated, be affected, the skin 
then has its vital energies depressed still further by a reflected 
sympathy with the organ in question. Thus, shivering is not only 
a symptom of the depressing cause of cold, but it is equally a 
symptom of an attack of inflammation having commenced in some 
internal organ. 

But it is a notorious fact that people are not attacked by 
internal inflammation who are in really good health : their previous 
habits or their previous condition almost universally unfolds either 
reasonable grounds for a belief in a disordered condition of the 
oeconomy, or symptoms which shew it to have been demonstrably 
present ; and this is so true as to be almost invariable. Sometimes 



331 



these refer to one organ, sometimes to several ; sometimes to the 
organ wherein the inflammation is seated, sometimes to other or- 
gans. In fact, it is evident that inflammation is set up in a part 
where it is quickly destructive ; and therefore, if inflammation be 
naturally a preservative process, there must be here some interfer- 
ing influences ; and we have hitherto remarked on the evidence of 
that interfering influence being referrible to previous disorder ; but, 
in carbuncle, boil, gout, and other links of the chain of inflam- 
mations, we also deduced evidence of a local character in those 
manifest departures, in these diseases, from more healthy kinds of 
inflammation. Now, if we look at the inflammation of internal 
organs, and especially of that most common of them, membranous 
investments, we find the local characters much more allied to un- 
healthy inflammations than to healthy specimens of this process, 
as has been noticed already. 

These considerations, whilst they account, on the ground of 
acknowledged facts, for the inflammation consequent on depressing 
influences on the skin taking place in or on internal organs, and 
whilst they explain, in various cases at least, why a particular 
organ is attacked, shew, like many other things described in this 
work, the real relation of the blood to the inCammation, — 
namely, that, however necessary it may be thought in certain cases, 
in the present state of our knowledge, to lower the actions of the 
whole system, in order to diminish those of the inflamed part, by 
thus abstracting blood from it by an influence directed to the gene- 
ral mass of blood, and also shew that the general quantity of blood 
is not the essential cause of the inflammation ; as it has also been 
shewn that the effect of its abstraction is not due to the quantity 
abstracted. 

This again shews the inestimable value of a consideration of 
the sympathies of organs in explaining diseased phenomena ; for, 
when internal organs are disordered, and still more when they are 
diseased, they always afl'ect the skin ; so that it never can carry on 
healthy inflammation. It either refuses the power altogether of 
taking on this inflammation, consequent on enduring disorder of 
function; or else declares its inability, in either establishing in 
itself, or in conjunction with the subjacent cellular tissue, those de- 
partures from healthy inflammation, boil, carbuncle, erysipelas, &c. 

All this points to the equalization of the circulation as the desi- 
deratum in arresting inflammation 

The actual state of our knowledge on this subject is so imper- 



332 



feet (I mean as to the mode of suddenly equalizing the circulation, 
so as to prevent the impairing effects of inflammation on the vital 
organs), that we are obliged to stop it at any rate, and hy any 
means in our power : but that we shall, in time, arrive at the 
attainment of such power, is, in my opinion, by no means an un- 
reasonable expectation. The progress wiYL perhaps be slow, in 
consequence of the absence of opportunity ; for, whilst we can 
certainly stop, in the majority of cases, inflammatory processes, we 
shall willingly compromise the prospective inconveniences of great 
depletion, in the reflection that we have preserved life, or a valu- 
able organ, as the eye. But still the investigation may progress ; 
and large or hasty abstractions of blood be limited to the most 
urgent class of cases, until advancing science shall give us the fur- 
ther information requisite for proceeding with confidence in treating 
inflammation by restoring equilibrium, and this again by attending 
to what are called its remote causes. In the mean time, we may 
avail ourselves of the following opportunities : first, where patients 
refuse to be bled ; secondly, where we have bled as much as we 
dare, without subduing the inflammation ; thirdly, in doubtful or 
masked cases ; and, lastly, in cases w^here, though the inflamma- 
tion be visible and pure, yet it is accompanied by such derange- 
ment of particular organs as to strongly suggest the idea of their 
producing the determination to the surface afl'ected. I shall shew 
you by and by, in connection with the treatment of inflammation, 
that such cases afford the highest promise of increasing our know- 
ledge, and, through it, of improving our practice. 



333 



DISCOURSE IX. 



REMARKS ON ULCERS, FISTULA, AND TUMOURS, IN RELATION 
TO THE LAW ENUNCIATED ; ALSO ON CERTAIN APPARENT 
EXCEPTIONS TO THE LAW, AS PRESENTED IN JOINTS, VEINS, 
THE EYE, ETC. 



ULCERATION. 

Now ulceration, or ulcerative inflammation, as it is descrip- 
tively termed by Mr. Hunter, is a glaring exhibition of a natural 
process, inasmuch as for one case which occurs otherwise situated, 
a thousand occur under circumstances where we have the advan- 
tage of comhininrj observation of local processes with the functions 
and manifestations of the whole oeconomy. As this is the case so 
far as the surface of the body is concerned, ulcerations afford evi- 
dently too obvious an illustration, as far as they go, of dispositions 
of inflammatory actions to the surface, to render it necessary that 
I should enlarge on that subject ; but they also appear to me to 
shed a very useful and beautiful light over the real causations of 
inflammation and the design of Nature ; or, to speak more philoso- 
phically, the laws of Nature of which they are the emanation ; and 
it is to this that I now claim your attention. 

At page 245, I have given a general description of the ordinary- 
local phenomena of ulceration ; and these we will yet consider a 
little more narrowly. An ulcer is not a mere abrasion of surface 
when it wants only the skin to cover it ; it is a very diflerent thing 
from that presented by a mere removal of a portion of skin from 
w^hatever part it is taken. It has, in no respect, the same charac- 
ters : we know that, from whatever part of the body a piece of skin be 
removed, we shall find fasciee, cellular tissue, muscles, bone, &c. 
as the ca^e may be ; but we cannot find, nor hy any direct mode 
of art at once make, an ulcer, any more than we can make a sto- 
mach. Under all and every circumstance, however varied, there 
must be a secondary process,-— a process emphatically set up by 



334 



Nature ; and, no matter whether it be of one kind or another, it is 
a structure which we cannot find in the natural state of the animal 
oeeonomj. It has vessels, nerves, secretions, of a peculiar charac- 
ter. As regards its vessels, we know that thej are extremely 
numerous ; that they are highly delicate ; that they easily bleed : 
as regards its absorbents, we recognize peculiar actions ; and, as 
regards its nerves, peculiar sensibilities : it is, in fact, no matter 
whether its effects be reparative, destructive, or whether its appear- 
ance remain more or less unchanged, a different structure or a new- 
structure ; just as the fistula, in which a deep-seated abscess may 
have terminated, is a new superposition on the natural or normal 
condition of the body. It is certain, therefore, that it must have 
some function ; and the question is, what is its nature* ? 

Some ulcers evidently seem to have no other function but the 
repair of an injured part, because the process is uniformly progres- 
sive ; and so soon as the part is restored, the ulcer ceases, with 
its functions ; the part heals, and the ulcer disappears, leaving no 
trace of its peculiarities, and scarcely a vestige of its existence. 
But many ulcers do not heal, nor can be brought to this process by 
art ; therefore, if a simple reparative ulcer w^ill heal of itself, and 
another ulcer cannot be induced by any means to heal ; it must 
either have a different function from a reparative ulcer, — there 
must be some interfering circumstance if its function be the same, 
since it cannot execute it, — or else it must have no function at all, 
which is an obvious absurdity. 

No process of Nature can be supposed to take place without 
some cause, nor without some object ; the propositions are in fact, 
truisms. The explanation of the cause would, no doubt, unfold to 
us the nature of diseases in general ; the discovery of their objects 
would at least facilitate the comprehension of their individual pe- 
culiarities. If these objects were fulfilled, they would be at once 



* Mr. Aston Key has written a paper on ulceration, which will be found in 
the seventeenth volume of the Medico-Chirurgical Transactions, in which, if I 
understand this gentleman aright, he is disposed to consider ulceration as a peculiar 
change or " disintegration of structure" in the part occupied by it. I have too 
much respect for Mr. Key to dismiss any paper of his in a few paragraphs ; there- 
fore I hope to have a better opportunit}^ of considering his views than I have at 
present ; but I may observe that, if disintegration of structure be regarded as an 
occasional effect of ulceration, I do not know that it is inconsistent with any views 
which I entertain on the subject : if it is to be regarded as the essence of the pro- 
cess, that is another affair. 



335 



apparent ; if they were not, the knowledge of such objects, if 
it did not explain the essential nature of the interference, would 
at least furnish us with the phenomena by which such interference 
or failure were accompanied. 

If inflammation, then, have any reference to any condition of 
the animal oeconomy, it is reasonable to infer, that when the in- 
flammation ceases, the condition causing it has ceased also : and if 
suppuration take place, and a spontaneous discharge of matter be 
followed by spontaneous healing of the part, it is just as reasonable 
to infer that the causes which originally set up the inflammation 
have ceased to operate ; and, on the other hand, if the suppuration 
contimie, as is the case in ulcers and fistulous sores, that the ori- 
ginal causes of the inflammation either continue in direct operation, 
or have been, somehow or other, followed by causes equally in- 
fluential. The foregoing is a series of propositions, just as tenable 
in regard to one science as another, — just as tenable in other 
sciences as in medicine or surgery ; because it only supposes re- 
lations of a general nature between causes and effects which do 
not arise out of the facts of any particular science, but to which 
mankind give assent with regard to all facts, and all reasoning 
whatever. 

That the secretion of pus is caused by some disturbance, or 
some peculiar condition of the animal oeconomy, has been sufficiently 
argued ; and that it ceases spontaneously, 1 mean without artificial 
interference, is well known : and that one of the characters of 
ulceration is, that the secretion of pus, or some of its varieties, is 
continued. This must have some cause ; and it will be interesting 
to enquire what that cause may be, whether it be in the part or in 
the constitution ; and then to see how far the phenomena of ulcer- 
ation militate against, or support, the view which I am enunciating 
with regard to the laws and causation of inflammation. 

All writers on ulceration admit the general influence which 
the state of the constitution is capable of exerting in the pheno- 
mena of ulceration ; and therefore I presume that the opinion of 
such a connection, in regard to certain cases, is admitted : it there- 
fore only remains to shew that the connection is universal, when I 
think we shall have no difficulty in referring it to the common laws 
regulating the occurrence of inflammation. We infer that an ulcer 
has a function, as it appears to me, on the same grounds as we 
infer that any other part has a function, because we cannot con- 
ceive that it has no object or function. 



33(3 



We see, in the spleen, for example, a peculiar structure ; we see an 
assemblage of vessels, nerv^es, and absorbents; we see that they are so 
combined as to give a peculiarity of appearance ; we see the spleen un- 
dergoing various changes bv disease, so that a very accurate descrip- 
tion of one spleen, say a healthy spleen, would not be a correct des- 
cription of another spleen which has been changed by disease. We 
know, however, nothing of the function of the spleen : we see it of vary- 
ing size and situation in various animals ; we know^ of instances even 
where it has been removed without material, and in some without 
any apparent, injury to the animal; but yet we never dream of sup- 
posing that there is not some purpose fulfilled by it in the animal 
oeconomy. 

All the essential part of the foregoing statement applies to an 
ulcer ; and now let us consider what may be the general nature of 
its object or function, and especially with a ^-iew to its constitutional 
relations. I\Ir. Hunter observes, in speaking of the formation of 
pus, granulation, &c. p. 453, vol. iii, op. cit. — " What organization 
this may be is not in the least known; nor must we wonder at this; 
for it is exactly the same with every other organ of secretion, about 
all of which we are equally ignorant. Indeed some of the differences 
between one gland and another are made out, and also sometliing of 
their general structure ; but not in such a way as can lead us to the 
actions and operations of the several parts upon which the nature of 
the diiferent secretions depend, so as to enable us to conclude, a 
priori^ that this or that gland must secrete this or that peculiar 
juice."' 

x\s I have already observed, an ulcer is sometimes a mere pro- 
cess of repair; that is, a vacancy artificially made (we suppose) 
is gradually filled by granulations, these are succeeded by the forma- 
tion of skin, and the part heals, as we term it: but the constitutional 
relations of this form of ulcer are, nevertheless, very important; for 
if the constitution be impaired, the reparative process does not take 
place ; and thus we learn that the simplest repair manifested in the 
part is really, after all, a process which implies the necessity of some 
accompanying condition of the animal oeconomy. 

Inflammation occurs in the leg, an abscess is formed, it bursts, 
matter is discharged, a certain district of the skin is removed, and 
it shews no disposition to heal. The interesting question is, why it 
does not heal' because the answer to that will explain its relations 
to the animal oeconomy, and in them probably the natural mode of 
cure. Now that the majority of these cases, and by this I mean 



337 



the majority of all ulcerations with which we are acquainted, are to 
be regarded as organs, the uses of which cannot safely be dispensed 
with, unless we remove ivith them the causes to which their functions 
refer, is in the highest degree probable ; and, in my opinion, demon- 
strable not less from reasoning than from facts which are almost 
equally well known to the public and the profession. These facts 
are the following: 

In the first place, it is well known that many ulcers resist for 
years all attempts to heal them by local measures ; secondly, in a 
variety of instances, the same ulcers heal very readily, either by 
the addition, or by the simple influence of measures directed to 
correct certain disordered conditions of different parts, or of the 
general state of the animal oeconomy. 

Thirdly, that, in a vast number of examples, when an ulcer is 
healed, it very speedily reappears after the cessation of local mea- 
sures. 

Fourthly, that ulcers are often preceded by well-marked dis- 
orders, which subside on the occurrence of the ulceration. 

Fifthly, that, in many cases of the healing of the ulcer by local 
measures, the disorders which preceded the formation of the ulcer 
recur. 

Sixthly, that, in cases where no detectable disorder preceded the 
formation of the ulcer, very palpable and various disorders oc- 
cur on its healing, and particularly if this be the result of local 
measures. 

Seventhly, that, on the contrary, the healing of ulcers sponta- 
neously is not usually attended by any unfavourable results. 

Eighthly, that those healing under the influence of measures 
directed to correct any disordered conditions, and to maintain a tran- 
quil condition, are healed permanently ; and that exceptions to this re- 
sult can be satisfactorily explained from some circumstances of inter- 
ference. Now, of all these facts*, every surgeon must have 
met with examples ; and I refer them to some particular condition of 
the constitution, which condition they contribute to relieve, because, 
whilst the whole phenomena seem easil}' reconcileable with that con- 
clusion, they appear reconcileable with no other. For example, a 



* " In teaching * ulceration,' I shall not rest content with the simple asser- 
tion : but I here only mention the facts in connection with the general law of in- 
flammation ; and surely they are too trite to require exemplification in a list of cases 
w^hich may be seen daily almost in any public institution." 



338 



woman has ulcers in both her legs, she has been under the care of 
different surgeons for six years ; I find that she has employed all 
kind of local remedies without success, until at length, wearied 
with unsuccessful attempts, she has given up the thing in despair, 
and pursues no other measure than dressing the sores with elder 
ointment, and taking opium, which has amounted (when I see her) 
to seven or eight grains daily, to relieve paroxysms of suffering. 

I gradually wean her from the opium. I tell her to poultice her 
legs, which she had often enough done before ; and I regulate her 
diet, and pay attention to her bowels, which had not been done 
before. I contemplate employing local remedies, in the hope that, 
under what I conceive to be more favourable auspices, they may 
succeed better ; but, finding the sores amend, I postpone the exhi- 
bition of the local remedies ; and, in two months, these enduring 
ulcerations, occupying, in the aggregate, a large share of both legs 
below the knee, are healed. How can I resist the conclusion that 
they depended on the state of her constitution ? The opium had 
nothing to do with their origin ; they existed for years before she 
took any opium ; neither did they heal on its withdrawal. I see 
no mode of avoiding the conclusion which I have mentioned. 

But this case, which occurred many years ago, is only one of a 
multitude of similar examples. Of all the other positions I have 
seen equally striking demonstrations ; but there would be no rea- 
sonable limit to this section, were I to adduce examples of every 
trite fact which I mention. Some severe ulcers seem to present 
exceptions to the opinion which refers their maintained existence 
to states of the constitution ; and these should be mentioned. 
That varicose veins give rise to ulcerations of an obstinate and 
intractable kind, and that whatever mode be adopted, that one very 
distinguishing feature in their history is their liability to recurrence, 
are facts well known. 

The above, however, is readily explained ; because, whatever 
has caused the varicose condition of these vessels has supplied the 
element of its continuance in the disorder of their mechanism to 
which it has given rise. The valves act imperfectly; so that, even 
although the circulation generally be put right, it does not follow 
that the original structure of the valves is restored ; and thus the 
veins,— which had their valves deranged by being called on to sup- 
port columns of blood to which they were naturally, or had become 
by age, unequal, — are, in their deranged condition, incompetent to 
the discharge of their natural functions ; so that, whenever the up- 



3.39 



right position is restored, the ulcer will recur. That this is the 
explanation of such cases, seems the more probable, from the most 
permanent relief ( cceteris paribus ) of such cases consisting in the 
obliteration of the veins in which the valves exist, and in obliging 
the blood to return by the deep-seated ones, which have no valves 
— a mode of treatment first recommended bj Sir E. Home, but 
afterwards in a more safe and judicious manner by Sir B. Brodie*. 
They are thus in the condition of parts organically diseased, which, 
wherever situated, are found not to be able to execute their natural 
functions : wherefore, in such cases, the correction of the condi- 
tion of the w-hole ceconomy, which gives them only their natural 
share of labour, still imposes on them more than, with this change 
of healthy structure, they are able to perform. Whilst the excep- 
tions which varicose ulcers seem to form to the usual laws regulat- 
ing the phenomena of ulceration are thus explained, no set of cases 
more irresistibly enforce on us the connection of their primary oc- ^ 
currence with disordered conditions of some part of the animal 
oeconomy. Local circumstances and peculiar occupations, no 
doubt, add force to the operations of constitutional causes ; and the 
usual depending position of the lower extremities is probably the 
explanation of these parts being the seat of such affections ; but 
this does not explain the actual increase of blood in the veins ; 
whilst there are many other conditions that do, and that very satis- 
factorily ; whilst the examination of the cases exhibits ample evi- 
dence that these conditions refer commonly either to the liver, the 
heart, or the general condition of the circulation; so that you 
scarcely ever find a case in which evidence of disorder of one or 
other kind is not palpable, either as the result of age, functional 
disorder, or organic disease. 

In a large number of examples, wC see very interesting pheno- 
mena in connection with ulceration. In cases where we can most 
unquestionably refer ulceration to some general disturbance of the 
animal oeconomy, we find phenomena which appear most instruc- 
tive. If the health improve in such cases, the ulcer diminishes ; 
if it retrograde, the ulcer enlarges, or there is some evidence of in- 
crease or alteration of function. Now this is just what we find in 

* Sir Everard Home recommended the ligature of veins in certain cases ; but 
this was found to be dangerous. Sir B. Brodie simply advised their division, so 
conducted that the opening in the vein and that of the integuments did not corre-' 
spond. The advantages and the conditions they imply will be more fully discussed 
hereafter. 

Z 2 



340 



other organs wliich are natural stnictures. If the system be disor- 
dered, one or more of these organs — that is, liver, bowels, or what 
not — have their secretions altered, or increased, or both : and just 
so it is in an ulcer. But there is another very interesting fact, 
that, in disordered conditions, the ulcer very commonly increases ; 
that is, its surface becomes enlarged ; and the analogy of this with 
what appear to be natural laws is very striking. 

Secreting functions have a very striking general connection ^^ith 
extent of surface, as we see in the alimentary canal, and indeed 
have reason to believe in all other secreting organs, which, so far 
as their structure is known, seem to consist of vessels or tubes 
divided to an almost inconceivable minuteness — one effect of wliich 
is evidently an enormous extent of surface. 

Nor is this general connection with highly developed secreting 
powers confined to animals. I have observed that,' in vegetables, 
where high development of colour is the function allotted to the 
corolla, there is an enormous extension of surface. I was induced 
to examine this point in a few flowers of highly developed colour, 
in consequence of the evidently ^^llous sm'face presented in connec- 
tion with the coxcomb, or Celosia Coccinea ; and I found that 
other flowers, having high development of colour, though they did 
not present a \illous surface to the naked eye, shewed one very 
highly so with a common magnifier. I was induced to place a par- 
ticle of the leaf of a Dahlia, which I had at hand, on the field 
of a microscope ; and it happened to be of the same colour as the 
coxcomb which I had examined with the naked eye ; when the 
similarity presented by the Dahlia was so striking, that, had any 
one told me it had been a portion of the Celosia, I should not ha\^e 
suspected the deception. Now, if the ulcer be obviously connected 
with disordered health, and increase with that disorder and dimi- 
nish with its diminution, or even if the contrary of these conditions 
occur (which also happens), the relations of its functions to the 
general health seems clear ; and that its increase of surface is, in 
fact, an increase of function. 

It follows, from this view of the subject, that ulcerations on the 
surface of the body become very emphatic demonstrations of the 
general law of inflammation: viz. a determination to the surface of 
actions calculated to relieve some disturbance of some part or of 
the whole animal oeconomy ; and if at present we are obliged to 
rest such views on rational and probable inferences from general 
and admitted truths, rather than on conclusions legitimately and 



341 



irresistibly drawn from established and particular, demonstrable 
premises, bj a close chain of reasoning, it is easy to shew that the 
facts are not to be blamed for it ; but that the fault lies in the pre- 
sent state of science, and that again on our mode of prosecuting it ; 
for, as I have stated, the general connection of superficial ulcera- 
tions with the general state of the oeconomy is demonstrable ; in 
fact, it is not questioned, that I know of, by any one : but how is it 
possible to carry out a demonstration of the particular relations 
when the solution is baulked by a perpetual alteration of local re- 
medies, with as perpetual alterations of various medicines ; though 
the fact were as easy as it appears to some difficult, whilst the co- 
existence of various local and general remedies were in combined 
operation ? We only arrive, in fact, at the reasonable inference, 
from cases where despair has dismissed the farrago of officious 
interferences with the processes of Nature, or where the alternation 
of the sore with certain states of disorder renders the relation, quo- 
ad that case, demonstrable : but we can multiply the demonstra- 
tion at will ; for I will undertake to say, that any man who will 
conduct half a dozen cases of ulcer in a manner hereafter to be 
pointed out, will easily obtain the demonstration in a form suffi- 
ciently unequivocal. 

This manner supposes the maintenance of the ulcer to have 
reference to some part or the whole of the general oeconomy ; and 
that, if the surgeon must have two or three remedial measures in 
simultaneous operation, he will at least conduct their application 
with intervals ; so that he may really have an opportunity of 
judging of the effect of one, or the inefficiency of all. 

Whoever will do this, may multiply his demonstration at plea- 
sure : but this would lead me to the treatment of ulcers, which I 
do not intend to discuss in this place. I am talking of the law of 
inflammation, as deducible from phenomena ; and I will only add, 
in this place, that the much-neglected sores of the extremities, the 
most common malady presented to the surgeon, afford the most 
fertile field for the demonstration of the real nature of disease of 
any one with which I am acquainted. These views of ulceration, 
while they explain how various the sensations of ulcers may be, 
and how diversified their appearance, adjust the real value which is 
to be attributed to their local characters ; namely, by leading us to 
associate them with the kind or degree of disorder, or with the 
particular organ of the functional or structural disturbance of 
which they are certainly the local manifestations. 



342 



It explains also how ulcers may heal very suddenly, without 
any, after having resisted all, local applications ; or (which has 
oi'ten much surprised surgeons) under an application which had till 
then been employed without benefit, or even with injurious effects. 

FISTULiE. 

I have said, in relation to the law enunciated, that one of the 
phenomena of ulceration is continued suppuration : and it will be 
necessary to consider another class of cases, in which this is 
the leading feature. I mean those secreting pipes in which ab- 
scesses of various descriptions sometimes terminate, and which we 
call fistulse. Now, looking at the obvious phenomena of these 
cases, we see that an abscess, either bursting, or having been 
opened, as the case may be, contracts its dimensions ; the sides 
coalesce, the suppuration ceases, and there is an end of the matter. 
In other cases, however, the abscess heals every where except in a 
particular line ; it continues to secrete, and if we examine it, by 
slitting it open, we find that there is a pipe or tube, presenting an 
entirely new structure. Nature has actually made a canal : it is 
not merely that the abscess has partially adhered, and left a given 
track unrepaired, but there is a newly formed structure, lined by a 
smooth, secreting membrane, which is just as distinct in its natm'e 
as the urethra or any other canal, from common cellular tissue. 
As these fistulae are not natural structures, it is reasonable to sup- 
pose that there is some cause for their formation. It is not that 
Nature does not heal the part ; her conduct is not, in this case, 
nor in any other, merely negative ; she is always doing something : 
but in this case she makes a secreting surface ; and to suppose that 
she develops a new structure without reason, is not only in itself 
a manifest absurdity, but it is contrary to every observation of any 
one part of her wonderful operations. The question is, then, what 
is her object ? — and this we shall investigate auspiciously, if we 
consider why these fistulee do not heal, — in other words, why they 
are maintained. 

Here again we must commence the consideration by the sim- 
plest cases. W e at once perceive that, in many cases, the reason 
is very obvious. If we have a fistulous track leading to a piece of 
diseased or dead bone, we cannot heal such a fistula : we may 
slit it up or scarify it, as we please ; but if we wait until the dead 



343 



bone is thrown off, then it heals without any interference whatever. 
Here is, indeed, determination to the surface provided for in a very 
elaborate manner ; and fistula is the mode in which it is performed. 

Urinary fistulse are also very instructive. Irritation is set up 
in the urethra, which becomes thickened at some part ; this of 
course narrows the canal, and consequently affords a growing ob- 
struction to the ejection of the urine. As the causes w^hich pro- 
duce this irritation and thickening are allowed to continue in 
operation and are probably in most instances factitious. Nature 
has no chance of removing such thickening and clearing the 
obstruction. She therefore, as she cannot preserve the ordinary 
calibre of the pipe through which the water is to flow, increases 
the power of the engine (in this case, the bladder), which becomes 
actually increased in its muscular mechanism. Even this, how- 
ever, is not sufficient ; for the canal gradually becomes so contracted 
as to be not only exceedingly small, but occasionally to be obli- 
terated ; so that the passage of the urine through the natural con- 
duit, becoming at all times very diflicult, at last may be impossible. 
Now, then. Nature opens a passage by ulceration : sometimes she 
includes the strictured part in such ulceration, and makes an aper- 
ture where of course it can only be of use, — namely, bebind the 
stricture, — that is, near the vessel which is to be emptied. In 
doing this she has provided, it is true, against an accident ; wliich, 
unless met by art, necessarily proves fatal, — that is, retention of 
urine in the bladder ; — and, therefore, the act is really preservative. 

Still, although safe as compared to the retention of the urine, 
it is a very serious occurrence The urine, flowing through the 
aperture thus made, is brought into structures with which this acrid 
fluid is not naturally in contact. The urine is essentially an ex- 
crementitious fluid ; almost any thing can be retained more safely 
than it. Coming, therefore, into contact with parts not endowed 
with the requisite functions, it must be got rid of ; and, as the ab- 
sorbents are apt to take up matters in many cases, even when 
such matters are injurious, it must be brought to the surface very 
quickly. It is the property of urine, and apparently for a good 
reason, to excite violent inflammation in parts not naturally des- 
tined to be in contact with it ; and its transmission to the surface 
(the inflammation being so violent) is very rapid. The surgery of 
these cases consists in expediting the process by deep and free in- 
cisions, so as to evacuate the urine by a direct opening, which 



344 

Nature, even in this rapid development of her process, cannot 
easily do, but by means of an extensive inflammation. 

The urine, however, once brought to the surface. Nature im- 
mediately sets to work to provide against the continuance of this 
disturbance. She makes canals or fistulse, through which the 
urine can flow without danger, and establishes in them a surface, 
imitative, if I may so say, of the natural canal. These fistulse 
continue, forming so many canals, endowed with a suppurative 
secretion, and allowing free exit to the urine. Now, various at- 
tempts have been made, in former times, to slit up such fistuloe ; 
but, unless the division included the contracted portion of the na- 
tural canal, or that were previously put right, they were of no avail. 
Now, we restore the natural canal, and learn the real cause of the 
continuance of the fistulae, in their immediately beginning to heal 
without any other operation ; and thus these cases are as tractable 
as they appear formerly to have been otherwise. Nor is that ex- 
planation correct which refers the cure of the fistulee to the urine 
flowing (as the natural canal is restored) where it meets with the 
least resistance ; for it would be difficult to shew that the various 
fistulous tracks ofl"er less resistance than the urethra ; for it is by 
no means an essential condition that the canal be restored to its 
natural calibre before the urine ceases to flow by the fistulous track. 
All which will be more fully shewn, of course, when the diseases of 
these important organs are discussed. 

Fistuloe occur also, as is well known, about the rectum ; and 
very interesting things they are, as presenting exactly a similar 
state of things, but so modified as to form a link between those 
fistulse the causes of which are readily perceptible, and those 
wherein the causes are obscure or unknown. Cases of fistula in 
ano present examples both of one and the other ; with this addi- 
tion, however, that for one in which we cannot trace the cause to 
some condition of the whole, or some important organ, of the ani- 
mal oeconomy, a vast number occur in which the connection is 
easy and palpable ; so mach so, that it matters little whether we 
select our evidence of this connection from the history, progress, or 
treatment of the case, or from one which has been unsuccessfully 
treated, or otherwise. I have operated on as many fistulse, pro- 
bably, as most people of my standing. No cases in large institu- 
tions are more common than those in w-hich this operation is 
supposed to be required ; and therefore I speak with the confidence 



345 



of experience, when I say that no fistula is ever formed by the side 
of the rectum without obvious disorder of the general health ; nor? 
indeed, without the situation of the disturbance being easily trace- 
able to some particular organ. 

The connection between these affections and disorders of the 
chest is well known and easily intelligible ; but the fact is all I 
need mention now. The relief which usually follows the inflam- 
mation and abscess, of which the fistula is the termination, is also 
well known. It is equally well understood not to be permanent, 
if the causes of disturbance are allowed to continue in operation. 
Moreover it is certain that the division of fistuise is frequently un- 
successful ; and I have frequently operated on those which had been 
unsuccessfully operated on before. This is usually attributed to 
the operation not having been properly performed, or the dressings 
carefully applied ; both of which may perhaps be the case on some 
occasions : but the more frequent cause is, that, neither before nor 
after the operation, is the requisite attention paid to the removal of 
the circumstances on which the disease depended, or the preven- 
tion of their recurrence. When this is done, fistulee do not recur ; 
and of this fact I am so certain, that if I knew a patient's habits, I 
would venture to predict vnth certainty whether his complaint 
would return, unless indeed he had some other malady substituted 
for it. 

The relief of these cases shews in other ways their connection 
with the general oeconomy, and proves, often enough, that the relief 
ascribed to the operation is in fact due to other causes. A patient 
is about to be operated on for fistula ; the discharge is consider- 
able, he suffers great pain, and so on : he is desired to keep quiet, 
poultice the part, to live low, to abstain from fermented liquors ; 
his bowels are well evacuated, they are kept regular ; and, espe- 
cially before the operation, means are taken to ensure the complete 
evacuation of the alimentary canal. Now all these things, which 
are undertaken as conditions favourable for the success of the 
operation proposed, are really those which strike at the causes 
of the malady : but the operation is performed, the part heals, the 
patient gets about, the surgeon takes his leave, and the patient 
has been successfully operated on for fistula. Granted. But we 
find that, in most cases, all the troublesome symptoms have sub- 
sided before the operation. The amendment of the health has 
relieved the pain and inflammation, — nay, it has lessened the dis- 
charge. To the latter, then, w^hich indeed is troublesome and 



340 



loathsome euougli, tlie symptoms are confined ; the operation, how- 
ever, is performed, and the cure ascribed to it. 

At one time I began asking myself why, under such circum- 
stances, I operated at all ; and I ended in operating, truly, in some 
cases still, — but for a very different reason from necessity ; and 
that was, to relieve the patient speedily from what he thought a 
great inconvenience. For the cases in which patients refused to 
submit, when the pain was removed, and those in which further 
experience induced me to leave the operation as a matter of 
option, shewed that the fistula either disappeared altogether, or 
dwindled to a very small sinus, with scarcely a drop of matter ; or 
else, if some suppuration continued, ceased to give any trouble. 

But any of these patients would soon become annoyed if they 
were incautious of their general health ; and many of them know 
very well the particular errors which reproduce the local disturb- 
ance : as errors in diet, for example ; or neglect of the bo\vels. In 
short, what I mean to say, generally, is this, — that, whether we regard 
those abscesses near the rectum which do not terminate in fistula, 
or those which do, they are always demonstrably connected with 
some disorder of the general oeconomy ; and that not only the 
general disorder, but its particular seat, is for the most part de- 
monstrable. Another fact, too, in regard to fistulee in this part, is, 
that the inflammation preceding them has all the characters which 
link it, in kind, with those inflammations in which disturbance of 
the general oeconomy is most clear and most universally admitted — 
I mean with erysipelas and boil. The action is violent ; the colour 
deep red ; the pain excessive ; the discharge highly offensive and 
pecuUar ; and there is almost always more or less sloughing of the 
cellular tissue, or skin, or both. Here then we have, in fistulae, a 
new organ, in which a suppurative process is estabhshed at the 
surface, in ob\dous relation to some condition of a part or of the 
whole of the animal oeconomy, just as we have in ulceration : which 
shews that both one and the other really consist of processes es- 
tablished at the surface for the relief of the system ; and that 
these processes are established by the agency of inflammation. 



TUMOURS. 



Tumours are a dissimilar family of diseases, which, regarded in 
connection with the preceding views, are susceptible of great sim- 



347 



plification. Whatever lias been said of the general connections of 
ulcers, is equally true of tumours. These bodies must have func- 
tions of some sort ; thej are, for the most part, organized ; and, 
v^here they appear most evidently not so, their contents may, with 
a certain degree of probability, be regarded as having no function. 
They are like foreign bodies, which remain in the body, surrounded 
by a cyst ; but, again, as this cyst has a function, the pervading 
simplicity of the law under which they become manifestations of 
disturbance, referred to the surface of the body, becomes equally 
apparent. I am prepared to shew how these laws are borne out by 
the practice to which they lead, and its success in obtaining the 
removal of the growths by natural processes ; which, although very 
different in different cases, yet is the same, in principle, in all ; 
namely, that which refers the tumour to some condition of a par- 
ticular organ, or of the whole animal oeconomy : in general, to both 
in conjunction. I regret very much that I cannot enumerate all 
the propositions, nor follow up the enumeration by all the facts, 
bearing on this point : there are, nevertheless, certain considerations 
with respect to tumours on which I cannot avoid adding a few 
words. 

Tumours are not usually considered as resulting from inflam- 
mation proper ; but their existence must be derived from the es- 
sential character of all inflammations ; namely, increased action. 
Mr. Hunter very truly observes, of lymph, as the product of 
ordinary inflammation, that this mode of separation of coagulable 
lymph is not confined to this species of inflammation ; it is sepa- 
rated, on many other occasions, to form tumours," where inflamma- 
tion does not seem to be the leading character. Now this is 
essentially a correct view ; it is only incorrect in gratuitously sup- 
posing that the substance, coagulable lymph, is the pabulum for 
the formation of tumours ; which, whether true or not, does not 
necessarily interfere with the law to which they may owe their for- 
mation. This subject, like many others, throws more or less light 
on the real law of inflammation ; but this process can never be 
fully discussed until its various modifications be considered, which 
cannot be done except by the consideration of many other diseases. 
Yet a few remarks may be mentioned here. 

Where that increased deposition, which forms what we call 
tumours, takes place once elsewhere, we find that it takes place in 
an incalculable frequency in the cellular tissue near the surface ; 
the usual seat of inflammation, in a primary sense, — more so indeed 



348 



(except it he in very small districts) than the skin. For, although 
inflammations appear on the surface so frequently, jet most of 
those which are extensive are not seated primarily in the skin, nor 
do thej usually destroy more of this than is sufficient for the dis- 
charge of the products of inflammation. We see a good reason 
for this, in that the skin is a much more important structure than 
cellular tissue ; its function one much more indispensable ; and we 
gather this from its ph}'siology direct, as well as from its pathology. 
Extensi\ e inflammation of the skin is always a serious affair, as 
we have seen in the extension of erysipelas to it, and as we shall 
presently observe in burns. 

Increased deposition is clearly a preservative process in Nature ; 
and it occurs under a variety of different circumstances. If the 
body be overnourished, the simplest remedy we know of is the 
deposition of fat ; but we have plenty of evidence that fat subjects 
are not the most healthy. This fat, too, is generally deposited 
w'\ere it produces least inconvenience at first ; but the extension 
of this process leads to inconvenience. Even then we seldom find 
it deposited first in any situation w^here it destroys function. We 
have it sometimes in a distinct site ; and this is an adipose or fatty 
tumour. But, as hypernutrition is neither the only, nor perhaps 
the most general, disorder which accompanies the formation of 
tumours, so we have a multitudinous family of these diseases, ex- 
hibiting every conceivable variety, so far as their physical charac- 
ters are concerned. Sometimes they are bony, cartilaginous, 
horny, or intermixtures of these ; sometimes they are like certain 
natural parts, as the mammary gland and sweetbread ; sometimes 
gelatinous ; sometimes firm and fibrous ; sometimes a texture, like 
an intermixture of fat and gland ; sometimes cellular ; sometimes 
like firm suet ; and consist of those various products which had led 
to the terms atheromatous, steatomatous, and melicerous tumours. 
Mr. Abernethy made a sort of classification, founded on their obvi- 
ous appearances, in connection with certain constitutional pecu- 
liarities, as shewing them to be of benign or malignant character. 
This is evidently the right road ; but the generalization is inade- 
quate to practical purposes. What we want, if their physical, 
or even their chemical, characters (a point to which lately more 
attention has been excited) are to help us to their treatment, is not 
the mere general fact whether they are curable or otherwise in the 
present state of our knowledge, but the particular state of various 
functions, in difterent classes, and in individual cases. We want, 



349 



in fact, the extension of Mr. Abernethy's plan; for, althongh I 
would be the last person to undervalue the chemical investigations 
of these tissues, — jet, as the disorder of the animal oeconom j which 
accompanies them must be the real desideratum, perhaps it is not 
too much, when we consider the very limited application of mere 
chemical reasoning in respect to life, to expect quite as much from 
their physical characters, as marking this connection, as from their 
chemical composition. Both modes of enquiry, however, are evi- 
dently not incompatible with each other, and should be both 
pursued. 

A great deal of light is thrown on this subject by the effect of 
operations ; and a great deal of false reasoning, in regard to them, 
requires correction, as I hope to shew when I come to consider 
this class of maladies. At present, nothing is more certain than 
that the removal of the tumour does by no means remove the 
cause of its production ; and, in many cases, the manifestation of 
the fact is the actual reproduction of the tumour. And I appre- 
hend I can shew, also, in due time, that tumours may be removed 
by the same powers that produced them, namely, the powers of life ; 
which, producing them when disordered, remove them on being 
restored to their natural condition. 

The liiuits of this volimie oblige me to postpone the considera- 
tion of the law of inflammation, as exemplified in different diseases, 
until an opportunity occurs for treating of these diseases in a full 
and proper manner. There are a few subjects, however, on 
which 1 will at once offer an observation or two ; w^hich, by their 
nature or frequency, are likely to suggest themselves as exceptions 
to the law which determines inflammatory actions to the surface : 
and, first, we will offer a few remarks on affections of 

JOINTS. 

Now here, as in other cases, if we wish to understand the real 
^lature of any one class of cases, we must trace the various other 
affections with which they are linked, and begin by collecting all 
facts in relation to the subject concerning which we enquire; but, 
as a great deal has already been done in this way in the preceding 
pages, we may at once proceed to put the reasoning and the facts 
together, so far as affections of joints are concerned. 

We cannot say that joints are, strictly speaking, the surface of 



350 



the body, though many of them, and those most frequently affected, 
are contiguous to it : we cannot say that they are parts unimpor- 
tant ; nor that inflammation of them is otherwise than a serious 
occurrence. Let us, then, consider briefly the circumstances under 
which they become inflamed ; and what objections they really 
afford to the generalization, in regard to inflammation, which I have 
proposed. 

Now, what do those very common affections of joints teach us, 
which occur in connection with gout, rheumatism, or scrofula ? 
Why, in gout and rheumatism, we see, first, inflammation noto- 
riously accompanied by disorder of the system, which disorder, it 
very frequently, and at first very generally, relieves. We see the 
pain, &c. referred to the joint ; but the inflammatory actions are 
transferred to the surface, and the cellular structures beneath it, 
so that the structure of a joint is seldom impaired by these diseases, 
— that is, gout or rheumatism, — until it has been repeatedly at- 
tacked by them. To this, as affecting natural power, it may be 
added, — that, at first, the causes of these diseases are generally of 
a removable nature. The disorder of the system is usually brought 
on by improper living, or exposure to cold, the body being previ- 
ously in a disordered state. 

These are causes which are obviously struck at by regulation of 
diet and temperature, and those secretions or excretions which 
may be impaired, — which is the common treatment of gout ; and 
the consequence is, as I ha\'e already observed, that it is only after 
the repeated or sustained operation of the causes of gout, that the 
structm'e of joints becomes organically impaired. The perfect 
manner in which parts thus recover, after gout, forcibly struck Mr. 
Hunter. But, besides the foregoing, it should be remembered, 
that, in gout, many circumstances contribute to leave Nature un- 
molested in her operations. Both gout and rheumatism are ex- 
tremely painful ; they neither of them require, ' from the medical 
attendant, any inj unction as to rest of the part ; they both prohibit 
motion by the pain which accompanies it. They are both com- 
monly attended by impaired appetite (another very curative cir- 
cumstance) ; or, if appetite be present, the indulgence of it is so 
rapidly followed by exacerbation of symptoms, as to prevent the 
repetition of such indulgence. The patient, in this case, bears 
about him the best of all physicians. Nature herself, who speaks 
so intelligibly that she cannot be mistaken ; and the consequences 
are, as stated, that the injury to the joint is trivial, until the repe- 



351 



tition of the causes has induced repeated recurrences of the disease : 
and surely it is not necessary to insist, that repeated attacks of gout 
or rheumatism impair the powers of the body. 

Now what 1 have stated, as so happy (although so painful in 
some of its features) an arrangement in gout and rheumatism, does 
not apply to scrofula. Here, in fact, many of the circumstances 
are reversed. 

The approach of scrofula is not ushered in by pain ; the dis- 
ease is insidious, and creeps on with a kind of stealthy, and too 
often in other parts with a kind of fatal, silence. The pain is very 
little ; the patients are generally young ; at the time when, of all 
others (if we are to talk of cure of the joint), rest is most essen- 
tial ; neither do the suggestions of Nature oblige, nor does the 
medical attendant enjoin, much less compulsorily ensure, that ahso- 
luie quietude, which is the very alpha and omega of the treatment 
of joints, and of all parts (whose vital powers are of a low order) 
when labouring under excitement. 

Digressing for a moment : I can in no way understand the fre- 
quent neglect of ensuring the quiet of diseased joints by splints, after 
what Mr. Abernethy taught for so many years on this subject, 
and which Sir B. Brodie more recently recommended. I never 
mention this subject without feelings of annoyance. I say, again 
and again, that I am certain I have saved more limbs from amputa- 
tion by ensuring absolute rest of diseased joints, than by any 
single measure whatever. To return : — I cannot here say all that 
must, in due time, be stated in connection with scrofula : but we 
know that the causes of this disease are much less within our 
power than those of gout, or even rheumatism. This, perhaps, is 
partly because they are less perfectly understood, and partly from 
our climate being so obnoxious to scrofula, that it very much in- 
creases the difficulty of availing ourselves to the full extent of what 
we really do know. Besides this, as I hope hereafter to shew, scro- 
fulous cases are often exasperated by many of the measures which 
are instituted with a view to relieve them. Then, again, joints are 
by no means the most frequent seats of scrofula. In an immense 
majority of cases, the subcutaneous glands, and the skin covering 
them, are the parts first attacked ; and this, in a vast number of 
cases, wherein the joints do ultimately become the seat of disease, 
— where, indeed, though the disease be serious, it is less so than 
in other structures which appear especially obnoxious to this ma- 
lady, — I mean the lungs and mesentery. 

We must not, however, measure, as natural processes, the va- 



352 



rious terminations of scrofulous affections of joints by the absolute 
number of cases in which either the joint is destroyed, the limb 
amputated, or even life extinguished, as they are (speaking of the 
mass) at present treated, — of which, more hereafter. 

Scrofula in the lungs, or even in the mesentery, is often, in fact 
perhaps generally, sooner or later fatal. In joints, properly treated, 
it is scarcely ever destructive of life, or, as I hope hereafter to 
shew, of the limb either ; so that, in point of real importance, dis- 
eases of joints are far removed from similar affections of the lungs 
or mesentery. In scrofulous affections of joints, however, it is 
interesting to observe, that notwithstanding that the part most 
liable to the disease is the bone, yet we almost always see some 
attempt to determine to the surface in the swelling around the joint, 
and in the effusion into the cellular tissue ; w^hilst, at more advanced 
stages, these appearances are changed : ulceration giving discharge to 
matter or other products, the results of the scrofulous inflammation. 
We also see in scrofula what is very material to the argument, — a most 
striking want of power, as contrasted with gout ; for whilst in gout 
the constitution will resist, for a long time, the influence of natural 
causes, strengthened by all sorts of artificial excesses, we cannot 
ensure in scrofula even resistance to the natural vicissitudes of the 
climate in w-hich the patient is born. I will only here add, that 
the most frequent and the most harmless exhibitions of scrofula 
are at or near the surface in the superficial glands, and the skin co- 
vering them : that the next in order of safety, and perhaps fre- 
quency also, are the affections of the joints ; and that these are as 
much preservative, in relation to disease of the lungs or mesentery, 
as affections of the superficial glands and skin are when contrasted 
with scrofulous affections of joints themselves. 

Reasoning then from these affections, in which disordered states 
of system, and their connection with inflammation of joints, still 
offer either successful determinations to the surface, or afford types 
of, or attempts at them, with insufficient power, we come to a 
class of cases in which the inflammation is less characteristic, more 
pure, as w^e phrase it, but which still exhibit a powerful determina- 
tion of diseased action to the surface, and with perfect success as 
regards the safetj^ of the joint: and be it remarked, notwithstand- 
ing the various injurious influences operating to the prejudice of 
natural powder, that even in a large city they are, beyond all calcu- 
lation, more frequent than common inflammation affecting the 
proper structure of joints. 

Every surgeon knows the following description of cure. A 



patient has pain and swelling in the vicinity of a joint ; he is dis- 
turbed, and the pain on motion compels the observance of rest ; 
the swelling increases ; it either points, or some district may afford 
more palpably the sensation of fluctuation, or, before pointing takes 
place, the fluctuation is unequivocal. 

The question occurs, in some cases of diflicult and in others of 
easy solution, — whether the matter communicates with the cavity 
of the joint ? and the decision that it is exterior (more or less con- 
fident in different cases), determines the surgeon to evacuate the 
fluid : this is discharged, the measures are continued, and the pa- 
tient speedily recovers. These cases are common enough. Here 
is a good example of them : 

William Payne, aged thirty-three, says that he has been confined 
some days to his bed, with pain and inability to move his right knee ; 
he is a journeyman coachmaker. The pain came on suddenly ; at 
first it was very slight, but in about twelve hours it had increased 
so much that he dared not move the joint. He reports himself 
temperate, and can attribute his complaint to nothing ; nor is he 
aware that he has caught cold. He dined on pork the three days 
previous to his attack, and is usually gross in his habits, living very 
much on the last-mentioned, meat and sausages. His bowels act 
daily ; but the discharges are dark or black, and very offensive. 
He is ordered to poultice the knee, and to take some calomel, with 
an aperient : if his bowels act freely by the morning, and he is 
then no better, he is desired to put on twenty leeches to the knee. 
The knee is swollen, elastic, and tender ; but he refers the pain 
more in the direction of the back part of the joint, towards the 
ham. Next day the bowels acted freely ; leeches were applied, ' 
which bled freely ; but he is still no better ; knee much the same ; 
but inflammation is more unequivocal near the surface. Two days 
after this he is rather better ; bowels still open, and the evacua- 
tions of a brownish and more natural appearance. Inflammation, 
which was extending up the limb, has become less. He can even 
now bend the joint very slightly without pain ; there seems to be 
fluctuation, and this, on attentive examination, seems to extend 
over the right side of the joint, some distance above and below it. 
I made an incision below the joint, and evacuated a large quantity 
of well-formed pus ; finding that the whole district of the fluctua- 
tion communicated as I had anticipated. The symptoms now 
rapidly subsided. 

Another very numerous class of cases, exhibiting the preserva- 

A A 



354 



tive tendency constantly prevailing with regard to the seat of 
inflammation, is seen in those cases in which the inflammatory 
disturbance is referred to the synovial membrane lining the joint. 
I do not here include those changes of structure of the part, as 
thickening, deposition of lymph, &c., concerning which Sir Benja- 
min Brodie has written ; but those where disturbance ends in effu- 
sion into the joint, either of its natural secretion (synovia), or more 
generally, perhaps, one of a more aqueous or less slippery quality. 
Whether these, or the cases I have just mentioned, stand first in 
the order of frequency, it is difficult, from individual experience, 
however large, to determine : but that both of them take prece- 
dence, in point of frequency, of other more serious afl"ections, is 
incontestible. Now, here again we see a determination doing 
least harm to a part ; and, as in the determination to the sur- 
face, we see another thing, and this a very essential one, which 
they possess in common, — viz. that the inflammation is determined 
to a part with higher powers of life ; that is, in fact, to say, with 
the greatest power of resisting inflammatory action with impunity. 

Now a vast number of these cases occur in practice ; and the 
only rational explanation of those first mentioned, afforded by their 
history, their symptoms, their progress, and their termination, is, 
that irritation, commencing in the joint, has been referred to the 
surface, where it has terminated in suppuration; but, when we 
have subtracted those very numerous examples of affections of 
joints afforded by gout, rheumatism, scrofula, and the purer kinds 
of inflammation which are determined to the surface, as in the 
cases to which I have just referred, undoubtedly there yet remain 
• many cases of inflammation of joints which cannot be regarded as 
falling under either of the kinds of disease which I hnve men- 
tioned ; nor can it be concealed that, in many of these cases, the 
diseases do, in different instances, practicall}- lead to disorganiza- 
tion of the joints, or, by affecting the health, to the amputation of 
the limb, and under circumstances which induce us to do this from 
the conviction that the amputation is necessary to the safety of the 
individual. But les us see how far these cases are really excep- 
tions to the laws I have mentioned. 

In the first place, the determination of diseased actions to the 
surface supposes, like every other preservative action of nature, a 
certain degree and a certam balance of power ; and, if this be not 
present, neither this law, nor indeed any other, can be perfectly 
accomplished. It is no more sound to argue that it is not a law in 



355 



the animal oeconomj to determine diseased actions to the surface, 
merely because they are not invariably placed there, than it would 
be to infer from indigestion that the primary process of assimila- 
tion is not the natural function of the stomach. 

If we can see an exemplification of this law or tendency in a 
thousand cases for one where we find an apparent exception, — to 
say therefore that the law does not exist, would be to argue from 
our ignorance rather than from our knowledge, — from the exceptions 
rather than from the rule. Now Mr. Hunter and Mr. Abemethy 
observed that, in disturbances of the constitution, parts were most 
likely to suffer which had least powers of life, or most suscepti- 
bility. The latter term is not very tangible as a ground for argu- 
ment ; but the former furnishes us with an idea on which we can 
agree as to the meaning. Now, although our notions of parts hav- 
ing little powers of life, like most other notions in medical science, 
are mixed up with something of error (or at least of assumption, 
which is gratuitous) — such as that these diminished powers result 
from the part being less sensitive, or less vascular*, as we term it — 
yet we can safely assert that certain parts of the body do most un- 



* The assumption is gratuitous, as regards comparative vascularity as the 
cause. We assume this, merely because we cannot demonstrate the vessels ; and 
this in the face of facts which convince us that thousands of animals, perfectly 
organized, exist, of which our external senses do not enable us to take cognizance, 
nor even the microscope to examine. Then again the fact of few vessels being 
visible by no means necessarily implies imperfect power. The cornea of the eye, 
in its healthy condition, is emphatically a part in which we can ordinarily discover 
no vessels, and it is very insensible ; yet I am not aware that I should be right in 
stating its power of life to be very subdued, even though that manifestation of 
vessels which it affords in inflammation were absent. We see the cornea support 
all those changes in disease which any other parts support ; the most unequivocal 
illustration of which is ulceration, because here we are sure that the actual 
substance of the membrane is the part affected ; in other words, that the affection 
does not reside in that modified continuation of the conjunctiva in front, nor of the 
membrane of the aqueous humour behind. There is a striking beauty in this power 
of the cornea ; for, were it endued with as little power as joints, it would be 
surrounded with destructive agencies, in consequence of its relations with parts 
having great powers of life combined with great exposure to disease, to which the 
destructive element of motion would be added ; so that we might reasonably infer, 
were its vital powers less, that disorder of the eye, in which the cornea is involved, 
and which now proceed so manageably as even to justify, under good treatment, 
the term trivial, would have been destructive of vision. There is indeed a great 
deal of exquisite beauty perceptible in the whole arrangement of the relations of 
this membrane : but I must speak of this hereafter. 

A A 2 



356 



questionably shew a greater disposition to perish, under diseased 
action than some others ; and, as nothing can be preserved under 
diseased actions by any other means than vital processes, so we 
naturally conclude that the vital powers of the parts in question 
are less than those of many other structures : such parts are bones, 
cartilage, ligament ; in fact, the structures of joints : and the phe- 
nomena of gout, rheumatism, together with affections arising from 
changes of temperature and many other causes, shew how readily, 
under an infinite variety of disordered conditions of the system, 
these structures become the seat of its local manifestation. These 
facts seem to me, therefore, rather to establish the law of inflamma- 
tion being a tendency to determine actions to the surface, in ex- 
plaining those circumstances which, as interfering with its opera- 
tions, appear, at first sight, to constitute exceptions ; for it cannot 
be too often repeated, that the clear development of any natural 
law in the animal oeconomy depends on the presence of natural 
power ; nor can the fact be too strongly impressed, that, in the 
cases where joints are attacked, they are often less important parts 
than those in which corresponding states of disorder are manifested 
where no affections of the joint occur. Thus, the same state of 
constitution, which, in one case of gout and rheumatism, produces 
affections of joints, will, where there is no affection of those parts, 
produce affections, much more dangerous, of the stomach, heart, 
and brain ; and, as has been already remarked, when scrofula does 
not manifest itself in joints or near the surface, it too often affects 
the lungs and mesentery. It is therefore, after all, productive of 
results in themselves preservative, in that joints, or the struc- 
tures of which they are composed, are thus placed under laws 
which appear to render them as insusceptible, under moderate de- 
gTees of disturbance, as they are susceptible, on the contrary, w^hen 
the disturbance of the oeconomy becomes more fully developed ; 
since the bringing of them thus within the reach of that degree of 
disorder which experience shews to be sufficient to develop disease 
in parts essential to life, renders these affections, as regards such 
vital parts as the brain, lungs, &c. a habitation for disease, just as 
really presers'ative as skin and cellular tissue are when considered 
in regard to joints. 

Finally, T would observe, as a matter of experience, to be more 
fully substantiated by facts, in their proper place, that affections of 
the internal or essential structures of joints (accidents or mecha- 



357 



nical injuries excepted) do never occur but in connection with very 
visible disorder of the system of some kind or other; so that, 
whether the presence of such disorder be admitted or not as a 
competent explanation (in the impairment of power implied) of the 
departure from w^hat I regard as the natural manifestation of the 
law of inflammation, whenever it arises independently of acci- 
dent, the fact of the coexistence of such disorder is indisputable. 
Now we observe certain aifections of the 



EYE, 

which, if we admit that they are inflammatory, seem to offer, at 
first sight, exceptions to the law I propose in regard to inflammation. 

I have already observed that an incalculable majority of the 
diseases of the eye occur on the surface of the organ (or the con- 
junctiva) ; and I have added that the most frequent cases are those 
in which the operation of internal causes is most manifest, as in 
scrofulous ophthalmia. It may be further observed that, when the 
proper tunics of the eye are affected, the external ones are by far 
most commonly the seat of inflammation ; the sclerotica, for ex- 
ample, as compared to the choroid coat, regarded as occurring 
without the operation of excitement or injurious influence directly 
applied to it from without, as is so commonly the case when a 
deeper-seated part than the retina becomes affected. 

Now we have in the eye a transparent part behind the pupil, 
called the lens ; and this is contained in a little bag or capsule : 
the opacity of one or both of these parts constitutes what we call 
cataract ; and we add the term capsular, lenticular, or capsulo- 
lenticular, as one or other or both of these parts are afi'ected 
respectively. It might be mooted as a question (had I any object 
in so doing), whether this cataract be inflammation at all ; but, as 
my object is truth, and not to carry on argument merely, I shall 
not hesitate to admit that this opacity does take place from a pro- 
cess not essentially different from inflammation ; since the cases 
shew that the existence of excitement is extremely probable, whilst 
the changes are purely of that character which we know inflamma- 
tion (when more obviously developed) to produce in transparent 
structures — viz. opacity — added to which, in many cases where no 
obvious excitement has existed, we have the capsule adherent to 
the iris in front of it ; in many of which cases I have myself ope- 



358 



rated. We also find that, when the lens or its capsule is mechani- 
cally injured, the result is opacity*. 

In regard to cataract, there are two circumstances very inter- 
esting ; viz. that, in all cases, we observe facts which can be ex- 
plained only on the supposition of excitement acting directly from 
without on the lens, or transferred to it from within, as a part 
nearer the surface, from an organ (the retina) affections of which 
are far more serious and irreparable than are any of the dis- 
eases of the lens. With regard to the excitement from with- 
out, the function of the lens is the transmission of the rays of 
light ; and there is no reason for doubting that excessive stimula- 
lation by light of great intensity, or for unusual periods, may prove 
directly exciting to this body, just as any excess of function may 
prove injuriously exciting to any other part ; and it is interesting 
to obsen^e that the opacity draws a blind, as it were, between the 
exciting cause. But a more important consideration, and one ap- 
parently more directly connected with the cause of cataract, is 
found in the following considerations, which evince alike that its 
occurrence is a determination to the surface, and is ( quoad the more 
important part, the retina) preservative. All causes of cataract, 
mechanical injuries apart, involve high excitement of the retina. 
We feel demonstrably the excitement of vivid light ; we feel the 
fatigue consequent on the continued excitement of distinct vision ; 
we know how much this is increased; and how much sooner it oc- 
curs, if it involve the examination of minute or glistening objects ; 
we recognize the effect of a country covered with snow in the ex- 
citement it occasions, in the same manner. Now we find practi- 
cally that the best-ascertained causes of cataract involve all the 
circumstances here mentioned. Thus, we find that persons most 
obnoxious to cataract are, cceteris paribus, such persons as watch- 
makers, those who are engaged in the construction of mathematical 
instruments, shoemakers also, in short, all those whose occupations 
require the constant exercise of distinct vision on objects which are 
minute or glistening, or both, and which occupation combines also, 
in greater or less degree, a position of the head favouring conges- 
tion of the eye. All these functions refer with especial force to 
the retina ; yet we do not see the inflammatory or diseased changes 



* This does not appear a necessary result in animals, when the capsule only 
has been intentionally wounded. — See Archives Generales de Medecine, October 
1826. 



369 



set up in this structure, but in the lens exterior to it ; and this in 
so large a majority of cases as to be of difficult calculation ; for, 
whilst cataract is a common occurrence from such causes, inflam- 
mation of the retina may be regarded as extremely rare. To 
shew that I do not speak without some experience in such matters, 
I may observe, in regard to the frequency of cataract, that, in the 
first ten months that I held the appointment of Surgeon to the 
Dispensary, which only relieves diseases of the eye in common 
with other maladies, I performed about twenty operations for cata- 
ract only. It appears from the foregoing, that, if we are to regard 
the changes in cataract as not essentially different from those re- 
sulting from inflammatory actions, they are to be regarded not only 
not as exceptions to attempts to determine to the surface, but, on 
the contrary, as capital examples of it, under circumstances which, 
a priori, we could not have expected. 

A variety of other considerations in regard to the eye throw 
much light on this subject ; but I am not anxious to multiply illus- 
trations ; since, if this work is to be continued, diseases of the eye 
will be necessarily considered as a distinct subject; and then, I 
trust, I shall be able to shew how beautifully they and other affec- 
tions of the system mutually illustrate each other. I would rather 
not here increase illustrations calculated to hurry the reader to 
conclusions which I shall value only as the result of reflection and 
enquiry. 

\ great deal of interesting matter arises from certain changes 
which appear incidental to age ; but these I postpone also to the 
time and place more proper for their consideration : I will only ob- 
serve, that that change of the cornea which w^e call the arcus seni- 
lis, and which consists of a more or less complete zone of opacity 
around the circumference of the membrane, is placed where it in- 
terferes least with vision, so indeed as not materially to impair it ; 
that is, in fact, in a part of the membrane farthest removed from 
the pupil through wliich the rays of light are transmitted. 

The next subject on which I must also, at present, be content 
with a few observations, is mfiammation of 

VEINS. 

I had intended, in considering the example which phlebitis 
affords of inflammation of internal parts, occurring both from 
injuries, in the ordinary sense of the term, and also without such 



360 



injuries — I had intended, I saj, to reason up to this question, 
though a much more frequent and marked example of an analo- 
gous circumstance, which occurs so often in connection with stran- 
gulated hernia ; but I found the section so long, that I have been, 
in my anxiety not to increase the size of this book unnecessarily, 
induced, somewhat reluctantly, to postpone the argument it affords, 
with many others, in favour of the law which it is my object to 
enunciate. Inflammation of veins, like all other inflammatory 
affections, may occur as a sequence to local injury, or without any 
exciting cause being perceptible ; the latter, however, is compara- 
tively a very rare occurrence, and explicable on the ground already 
considered. The more common examples in inflammation occur 
as a sequence on parturition, or the wound of a vein, as inflicted in 
the ordinary mode of blood-letting. It matters little what class of 
cases I select for observation, as the remarks, with greater or less 
force, apply to both. 

As inflammation of these vessels after vensesection, if it be not 
the most frequent, is perhaps the more familiar occurrence, it will 
perhaps best serve the purpose. Those who wish to see what hap- 
pens after parturition, either in regard to the veins of the uterus, or 
in those more familiarly known to be afl'ected in the local manifes- 
tation of what is termed phlegmasia dolens, will do well to consult 
Dr. Robert Lee's paper, in the Medico-chirurgical Transactions, 
on that subject. 

Now inflammation of veins in the arm presents us with the 
following facts : 

Undisputed inflammation of the interior of the vessel, as a se- 
quence on the wound of vensesection. 

A rarity in occurrence, which, regarded in proportion to the 
infliction of the wound (bleeding), is absolutely incalculable. 

The institution of this wound, for purposes and under circum- 
stances which, of themselves, imply disorder of the animal oeco- 
noniy, and which is accompanied by measures obviously tending 
(as bleeding) to diminish power. 

The failure of that extent of adhesion, which, if it do not itself 
limit it, is practically found to coexist in all cases of the limitation 
of membranous inflammation to the part wounded. The inflam- 
mation is, in fact, extended (" diffused"). 

The argument, therefore, that this apparent departure from the 
law results from previous disorder of the oeconomy, as designated 
in the term absence of natural power, is grounded primarily on 



361 



the extreme rarity of tlie occurrence, as compared with injuries to 
veins, and the coexisting evidence of disorder implied in the pur- 
pose for which the bleeding is instituted. 

Both these arguments derive support (in relation to some pecu- 
liar disorder of the oeconomj being the essential circumstance) 
from the following facts : 

That wounds in veins, in bleeding, are only, after all, a few of 
the occasions on which these vessels are injured. 

That, in the majority of cases, the local conditions following 
the wound in ven£3esection are of a nature calculated to disturb 
healthy processes. I refer especially to the careless manner in 
which the wound is generally treated, and the neglect on the part 
of the patient to observe that abstinence from motion which is at 
all times contributory to the well-doing of wounds which are to 
unite by adhesion ; and yet that the inflammation in question is, as 
I have above stated, rare. 

More positive evidence, however, of absence of power, in many 
of these cases, is seen in accompanying disease of the viscera ; and 
again of attempts to carry out the law of inflammation from the 
dissection of such cases ; so large a number of which prove fatal. 
Effusions into the cellular tissue of the affected limb, abscesses in 
the joints, or in various situations, — some of these being in the 
vicinity of the vein, others remote from it, — effusions in the chest 
or other parts, resulting from actions set up by the serous mem- 
branes, — have been singly, or in greater or less combination, present 
in almost every case — occurrences which, dangerous as they are, 
may be regarded as something more possible of recovery than con- 
tinued extension of venous inflammation ; just as abscesses of the 
liver or other parts, from injuries of the head*, may, through in- 
ternal inflammations, present better chances of recovery than ab- 
scesses in the brain ; there being cases of recovery of the former, 
none of the latter. 

You will perceive, also, that the same kind of argument applies 
in relation to the wound, and the inflammation of veins, considered 
as cause and effect, which I have mentioned in relation to ery- 
sipelas, tetanus, and other aff'ections. But the argument in support 
of the law, derivable from inflammation of the veins, can be only 
fully understood when these affections are more fully considered ; 
and when the facts put forth in the writings of Hunter, Abernethy, 



* Portal, Mem. de I'Academie de Chirurgie. — Cheston's Pathological Enqui- 
ries. — Larrey, Mem. de Chirurgie Milit. 



362 



Travers, Hodgson, Arnott, Carmicbael, Bresehet, Lee, Bouillaud, 
and others, shall have been duly weighed, as well as those con- 
nected with uterine phlebitis and phlegmasia dolens, to which 
most of the observations made on phlebitis, consequent on venae- 
section, will equally apply. I will only here add, that, in some 
cases of phlebitis, the determination to the surface is evinced in a 
number of abscesses forming in the course of the inflamed vessel ; 
and that amongst the symptoms are, usually, swelling of the limb, 
hot and dry skin, with a speedily exhausting fever, sooner or later 
of a typhoid character. 

The interesting phenomena, seen in connection with what we term 

SPECIFIC DISEASES, 

should also be considered ; but I have only opportunity at present 
for a few very brief remarks. The term " specific disease" implies 
a marked line of distinction, which, like all artificial distinctions, 
is not always, in a strict sense, demonstrable in nature. But still 
the term " specific," properly agreed on, may, in the present state 
of science, be regarded not only as unobjectionable, but as conven- 
tionally convenient. 

The simplest and least objectionable application of the term 
seems to me that which refers it to certain afi'ections of the sys- 
tem, which pursue a course singularly uniform in its character, 
whatever may be the accompanying peculiarities of the individual. 
Thus, small-pox, measles, scarlatina, perhaps syphilis, may, for the 
sense intended, be at present conventionally regarded as specific 
diseases ; since, although we see them variously modified in their 
severity, their danger, and their external manifestations, they always 
present some general similarity (especially the three diseases first 
mentioned) which is striking : small-pox, for example, appears at 
present to result fi'om some peculiar principle, which seems to pro- 
duce a peculiar disturbance in almost any system to which it is for 
the first time applied, or which has not been pre\dously affected by 
one other disease, " the cow-pox." I must, however, request the 
reader to observe that I am here stating rather the general opinion 
than any well-considered conclusion of my own. Reflection has 
furnished me with very strong doubts as to the truth of the ordi- 
nary impressions of mankind on all these subjects, arising from 
many facts in themselves indisputable, but which require a vast 
deal more thought than I have at present opportunity of indulging, 
before I dare say more on the subject. Looking then at " specific 



363 



diseases," as they are commonly termed, we observe that, in all, 
inflammation is set up on the surface of the body ; and in small- 
pox, measles, &c., as has been before stated, with marked benefit 
to the individual. We see disturbance of the system ; we see in- 
flammation set up on the surface ; we see the constitutional dis- 
turbance gradually decline ; and, as these favorable changes take 
place, the disturbance on the surface disappears. The close rela- 
tion of the general and superficial disturbance, as exemplified in 
small-pox, has been already remarked on. It is interesting also to 
observe, that, in inoculating for the small-pox, where the matter is 
presented to the surface, yet the inflammatory disturbance on the 
general surface does not appear to result from any sympathy of it 
with that particular surface to which the matter is applied, because 
the previous disturbance of the system seems essential to the es- 
tablishment of the general eruption. In measles and scarlatina, 
similar phenomena are observable, although the disturbance is not 
artificially excited by inoculation. 

In syphilis, also, we observe a remarkable tendency to throw 
the disturbing actions to the surface, as in the skin and the mucous 
membrane of the throat ; and although, in many cases, the gene- 
ral disturbance is so great as to render parts of low vitality, as the 
bones, peculiarly liable to become affected, — yet we still observe 
the same tendency of actions to the surface. First, we observe 
that there is a great disposition to transfer the irritation of the 
bones to the periosteum which covers them. Efl'usions take place 
beneath this membrane, which are gradually followed by inflam- 
mation and ulceration of the skin covering them, although the 
whole process is slow and indicative of subdued power. It may 
be further remarked, that the bones most commonly afi"ected are 
those near the surface ; as those of the skin, elbow, nose, and the 
cranium. If what we call syphilis be really a peculiar principle of 
any kind, it is at least curious that the very same statement applies 
to the influence of mercury, which I have plenty of facts to prove ; 
and, indeed, I have mentioned the kind of evidence in a case or 
two published in the " Unity of the Body," and the nature of 
which is of the kind up to that time wanted, as it deduces the 
eff'ects of mercury from cases where they cannot be confounded 
with those of syphilis, because the patients were not only not 
affected by syphilis, but took mercury for other disorders. The 
extensive use, or perhaps abuse, of this mineral, however, will pro- 
bably, before many years are past, afford plenty oi" similar cases. 



364 



I hope hereafter to adduce facts which, whatever may be the 
nature of these poisons, throw considerable doubt over the specific na- 
ture of the effects of either mercury or syphilis ; and which strongly 
suggest that the effects produced by them may also result fi'om other 
sources of disturbance, as dissimilar as they are unsuspected. One 
case bearing on this point has also been related in the work above 
mentioned ; but the subject is too extensive and important to be con- 
veniently combined with the present argument, or to be introduced 
otherwise than in its proper place in this work. I may only observe 
that the facts point at least to the probability that the diseased ac- 
tions to which they give rise are only modes by which the system 
endeavours to get rid of them, in common with some other causes 
of disturbance to which it is more rarely, and, in the present loose 
mode of investigating cases, less obsers'ably subjected*. I have at 
present, however, neither opportunity nor inclination to press any 
argument in relation to what we call specilic diseases : it is suffi- 
cient to obser\-e, that diseases which at first sight present types or 
evidence of being under peculiar laws, do not at least militate 
against that law to which I have referred the phenomena of inflam- 
mation ; but that, so far as they appear to affect the question, they 
tend rather to establish the universality of its operation. 

To return once more to apparent exceptions. We have, un- 
questionably, inflammations of other internal parts besides those 
mentioned in this Discourse. There is no structure of the body 
in which inflammation may not occur, — as the brain, stomach, 
liver, or any other of the viscera, veius, arteries, absorbents, and so 
on. There is nothing in the fact of all these parts being endowed 
with the power of becoming inflamed, that impugns the law of de- 
termination to the surface ; which I have endeavoured to represent 
as the one under which inflammation, apart from direct injury, 
occurs. On the contrary, the very admission of such parts being 
endowed with this power, when regarded in connection with the very 
rare occasions on which it is exercised, strongly suggests that they 
are apparent, and not real exceptions ; and shews more strongly, 
perhaps, than any thing else, the powerful tendency of the law in 
question. 

I have already stated the unmeasured frequency of inflamma- 



* It was to cases of disease in which the labours of the natural powers 
hare been enduring and tedious, but ultimately successful, that Mr. Hunter applied 
the phrase — " the disease wears itself out,"' as it were. 



365 



tion of the membranes of the braiu, in connection with cerebral 
disturbance, as compared with inflammation of the brain itself: 
the same statement appHes to inflammations of the pleura, or lining 
membrane of the bronchi, as compared with inflammation affecting 
the substance of the lungs ; and of the peritoneal covering in com- 
parison with those of the substance of the liver, or other abdominal 
viscera. Inflammations of the actual interior or substance of the 
viscera, then, are indeed verj rare occurrences, and very seldom 
occur primary phenomena in the diseases affecting them ; for what 
we usually call inflammation of these parts, is found, on examination, 
to be, in the majority of instances, inflammation of the surfaces 
which I have mentioned. This, again, is the more striking when we 
regard the vast quantity of blood sent to the organs themselves, — 
a condition apparently so favourable to one necessary element in 
inflammation — namely, congestion ; and reflect that, whilst the in- 
flammation occurs on the surface, the causes manifestly, in many 
cases, are directed to the functions of the viscera themselves ; even 
where congestion and disturbance amount to impeded circulation, 
as often happens in the lungs, still we see, as in asthmatic persons, 
great efforts to relieve by actions on the surface, in the secretions 
of the bronchi and skin. And when inflammation does occur, it 
is only where we have facts justifjang a presumption that the laws 
of Nature are interfered with by want of due power*. 

* I examined a body only yesterday, which presented a very common series 
of appearances, but which become very interesting when examined in relation 
to the law in question. I did not see the man alive ; but he was a tailor, and I 
was assured that his habits were very sedentary, independently of the necessit}'- in- 
duced by his avocation. He always had laboured under costive bowels, and occa- 
sionally great sickness of stomach ; and this was attended with indifferent health 
for the last seven years. During the epidemic and influenza of last year, he was at- 
tacked by that complaint, and he never entirely rallied afterwards, ultimately dying 
with symptoms referring to his kings, such as exceedingly difficult respiration, occa- 
sional spitting of blood, &c. — but not matter, as it appeared at least. His body 
presented a full, distended gall-bladder, opacity of the peritonaeum covering the 
liver and spleen ; adhesions, and opacity of both pleurae ; and opacity of the peri- 
cardium covering the heart, one portion of which was become of the structure 
of cartilage. There was also slight effusion into the ca^dties of the pleura and 
pericardium. No observable change, however, could be observed either in the 
spleen, liver, or heart ; but the lungs were extensively tuberculated ; and there 
was a very vascular condition of the mucous membrane of the trachea and its 
ramifications. This is a very common sort of case, the cartilaginous deposition on 
the heart only excepted, and which, on being carefully peeled off, shewed the mus- 
cular substance not to be involved in it. I therefore make no comment on it, but 
let the reader make his own. 



366 



Thus it is a law, that a wound should heal bv certain processes 
which we can obsers-e ; and, in the face of such constant examples 
of such healing, we never regard it as otherwise than a law, merely 
because certain wounds cannot be brought to exhibit the reparative 
processes, or even because they occasionally produce erysipelas or 
death. Viscera do not inflame, except when the causes producing 
the disturbance have been allowed to be in continued or repeated 
operation, as those resulting from en'ors in diet or mode of li\-ing, 
or until the attempts to determine disorders to the surface haye 
been already made, and certain changes produced in the mem- 
branes or surfaces to which I have alluded. Cases, however, maj 
be excepted, in which, from causes not known, there is a tendencv 
to some particular disease, — as scrofcda, for example ; but all these 
conditions reduce the powers of life, and consequently modify, im- 
pede, or altogether interfere with the carrying out of the laws ; and 
not only the laws of inflammation, but ob\T.ouslj those on which 
power generally depends, as digestion, &c.. and which are necessary 
to preservation. To develop all that might be urged on this point, 
or perhaps all that the present state of science renders necessary, 
would require a book which, unless published under the sanc- 
tion of very high authority, would, I fear, neyer be read ; or a 
course of lectures, which I have neither an opportunity, nor a 
proper arena, for delivering. But I am not anxious to carry men's 
comictions by storm, as it were. I only beg of my profession to 
think for themselyes ; and I look forward with confidence (though I 
may not live to see it) to what will be the nature of their conclusions. 
I have thus stated as much as the general objects of this work 
allow of, in connection with that which I here yenture to propose 
as the law under which every variety of iriflammation occurs. 

I must beg the reader to recollect that I have been obliged to 
select, on all points, only a portion of the e^ddence which bears on 
the general argument ; so, in the selection of exceptions, I have 
inserted those which to me appeared most striking, or most difficult 
of explanation: but as different parts of a subject impress various 
minds in a different manner, it may very readily happen that the sug- 
gestions of my own mind in these respects may be different from those 
which may occur to the minds of others. I am far from regretting, 
however, that an absolutely fall consideration of the subject was 
inconsistent with the more general, and I hope too the elementary, 
character of this work ; for every thing that is proposed as new, 
especially if it be important, should be received with caution, and 



367 



be subjected to the severest tests furnished by Inductive Philoso- 
phy. No author, who is really in quest of truth, will complain of 
any severity of examination ; he will not only patiently abide it, 
but, for a time, expect not only doubt, but opposition. As I write 
to diiferent classes of readers, I shall therefore, for the sake of 
being clearly understood, sum up the argument in a few short pro- 
positions, before I proceed to the " General Treatment of Inflam- 
mation." It appears, then, that — 

1 . Inflammation is essentially a reparative process ; and that 
wherever it appears otherwise, it is in consequence of a disturbed 
condition of the animal oeconomy. 

2. That as all parts may require reparative processes, so all 
parts are necessarily susceptible of inflammation. 

3. That in the repair of injuries of a mechanical kind, the 
repair consists in a restoration of the part, or an eflicient substi- 
tute for it. 

4. That all inflammations not obviously instituted for the pur- 
pose of repairing lesions of structure, are, without exceptions, 
endeavours to get rid of injurious influences, by transferring them 
to the surface of the body ; which is the law I propose to establish. 

5. That whatever exceptions occur in regard to this law, or in 
regard to the repair of mechanical injury, they are alike referrible to 
deficient power ; this deficiency arising from a disturbed condition 
of the animal oeconomy. 

6. That, in almost every case of failure of the healthy carrying 
out of the law which determines injurious actions or influences to 
the surface, we still see manifest types of endeavours at its fulfil- 
ment. 

7. That the healthy exemplification of law in the animal 
oeconomy requires the presence of natural power. 

8. That neither heat, redness, pain, nor throbbing, can be re- 
garded as essential characters of inflammation. 

9. That increase of bulk (swelling) probably is essential to 
inflammation, though not always demonstrable. 

10. That there is no necessary connection betvv-een the general 
mass of blood (qtioad quantity) and the occurrence of inflammation. 

11. That determination of blood to a part (congestion) may 
occur without inflammation ; but inflammation cannot occur with- 
out congestion or determination of blood to the inflamed part ; 
wherefore such determination is an essential element in inflamma- 
tion. 



3()8 

12. That, notwithstanding the foregoing be an essential element 
in inflammation, yet the essential character of inflammation is in- 
creased action of the blood-vessels. 

13. That whatever determines inflammation to a part, neces- 
sarily first determines the blood to that part ; and whatever this be, 
it is, in a given case, the real cause of inflammation. 

14. That this will be found to consist in a disorder of some 
organ, or of the whole oeconomy, or both in conjunction ; and that 
the determination to the part takes place in vu'tue of the sym- 
pathies of all parts of the body with each other acting in com- 
pliance with the law above enunciated. 

15. That, consequently, the treatment of inflammation ulti- 
mately resolves itself into measures calculated to equalize the 
circulation, as regards the inflamed part, and especially through 
the correction of any accompanying disorder ; and this ^ve next 
proceed to consider. 



369 



DISCOURSE X. 

TREATMENT. 

In the treatment of all diseases, the important desideratum is 
of course to remove the cause of the malady ; and where, from the 
nature of the cause, as in many examples of severe injury, or 
from our ignorance of it, as happens in many diseases, this cannot 
be done, — then the chief object is to influence the effects, so as to 
render them as little injurious to the body as possible. 

If I have rendered myself intelligible, and succeeded in giv- 
ing you true views of the nature of inflammation, the princi- 
ples of its treatment ought to be clearly deducible from them. 
Your general plan, whether to remove the cause or obviate its 
effects, ought not only to be in harmony with those views, but to 
arise out of them as an unavoidable induction ; and, further, not 
only should any good effects which you may obtain from the ap- 
plication of the principles flowing from such views be in harmony 
with them, but any success which you may obtain by means 
which you do not deduce from them ought to be exphcable, if not 
by their aid, at least on grounds in no way furnishing objections 
to them. Any thing less than this, though it might or might not, 
according to the extent of our knowledge, overthrow the views in 
question, would yet justly put them in abeyance, and suspend, at 
least, our conclusions in regard to them. I know not how they can 
be subjected to a severer test than that implied in the foregoing : 
but this test is necessary ; nay more, if we could discover any 
other views which appeared to harmonize in all respects equally 
well with any explanation of all the phenomena, this discovery, 
though it might not necessarily prove the view^s false, would equally 
oblige us to stop short of conviction, to rest them on probability 
only, or reject them altogether. 

Now these views suppose, as primary facts, nothing but what is 
demonstrable. In all cases whatever, there is in an inflamed part 
more blood than circulates in it in health, or in its natural condi- 

B B 



370 



tion ; and this is only another way of saj ing that the circulation, 
as regards the wliole body, is unequal : the two propositions are, in 
fact, convertible forms of expression. 

There is also demonstrably increased action in the part ; for 
whether we use this phrase in the sense of new, different, or addi- 
tional action, still the fact remains the same, — it is tme and demon- 
strable : and we know of no form of inflammation which does not 
bear out these primary propositions. They imply, therefore, two 
states, which being common to all varieties, shades, or degrees of 
inflammation, mast be held as their essential characteristics; and, 
as regards the subsequent phenomena, as the nearest link in their 
causation. 

It necessarily follows, in pursuing the chain of causation, that 
the next link will be found in any thing which can determine more 
blood than usual to a particular part : and though the influences 
capable of doing this be one or a thousand, it matters not ; for they 
will all have this property in common ; that they are all capable 
of producing the first, and always a necessary element in inflam- 
mation. Since, as I have before observed, although more blood 
may be circulating in a part than usual, without the necessary in- 
duction of inflammation, yet inflammation cannot occur without 
there being more blood in the part. 

Now you have already seen that the circumstances capable of 
determining more blood to particular parts are exceedingly various. 
Local injuries, mechanical or chemical, are one class of causes ; 
and the multilbrm phenomena of sympathy shew, that, as any one 
part of the body may sympathize with any other part of the body, 
and as the mode of manifestation of this sympathy may be very 
various, so determination of blood to a part may be one of them, 
as has been already sufficiently impressed. 

Further, as mechanical or chemical injuries form but one, and 
that certainly not the most dangerous, and perhaps even not the 
most numerous, class of cases \vhich we have to treat, so it follows 
that certain conditions of the body, whatever those conditions may 
be, must be regarded as a very fruitful source of the causes of in- 
flammation ; and, as the sympathies of parts present at least one 
competent cause for the institution of the first element necessary in 
inflammation, hence they must be regarded as at least one source 
of its causation. 

It has also been suggested that inflammation is a process of 
which the natural tendency is essentially preservative, whether we 



371 



use this term in the sense reparative, as in mechanical injuries, or 
as preserving the health of the body, or restoring it when subjected 
to injuries of a nature more refined or more general in their opera- 
tion ; and that, in this repair, the natural law consists in a deter- 
mination to the surface of the body ; and that, where this natural 
law is not carried out, there is an absence of natural power. 

Here, then, as regards the chain of causes which produce in- 
flammation, we arrive at another link ; viz. in that state of the 
oeconomj, or of any part of it, which rendered that determination 
of blood to a particular part (the primary element of inflammation) 
necessary ; for this must be, as it were, the ultimate link in the 
chain : since, although the power which determines the blood to a 
particular part be exercised by the vital properties or sympathies of 
this or that organ, and although the cause which renders the exer- 
cise of this power necessary may be proximately referred in many 
cases, and perhaps in all, to the organ in question, — yet the induc- 
tion of that necessity may have resulted from influences directed 
to it through its sympathy with other organs. Thus, suppose there 
be a state of liver, for example, producing determination of blood, 
and inflammation in the skin, or in the membrane which covers 
the liver (the peritonaeum), the proximate cause may be in some 
disordered condition of the liver ; bat then this, again, may be a 
primary affection of the liver, or a sympathetic disturbance result- 
ing from its sympathy with the stomach, or skin, or some other 
organ. Or if the primary determination of blood to a part, and 
the institution of inflammation, be the consequence of local injury, 
and the natural and healthy conduct of its repair be either imper- 
fect, or altogether fail, the absence of the natural power may either 
result from the state of the oeconomy, as induced entirely by the 
primary condition of a particular organ, or from this condition as 
the nearest link ; the farther one being in the disorder of some 
other organ, by which that of the one representing the proximate 
link may have been occasioned. 

The objects thcD, in the treatment, appear very manifest ; and 
the first is, to discover what agent that is which has determined the 
blood to a particular part ; secondly, what agency it may be which 
maintains that condition ; thirdly, if we cannot discover these, sup- 
posing them to involve difl"erent agents, which is often the case in 
local injuries, -the next point is-to minister to the next link in ap- 
proximation, and endeavour to remove it (if the removal of the 

B B 2 



372 



cause be impracticable) by any other means in our power. In 
other words, we should attempt to equalize the circulation ; and, 
if we cannot affect the subduction of inflammatory excitement by 
taking aw^ay its essential pabulum, tlirougli such equalization of the 
circulation, we then try whether we cannot either take it away by 
some artificial means, as local or general blood-letting ; or deter- 
mine it to some other part, by creating an inflammation in a part 
where it is either less dangerous, more manageable, or both; or, by 
reducing the powder of the body universally, to reduce that of the 
part, so as to deprive it equally of the powder of determining blood to it, 
or that of making use of it for purposes of inflammation. These, then, 
are the several points involved in the treatment of inflammation. 
I would add, how^ever, that, if inflammation be an attempt to de- 
termine injurious influences of a general kind to the surface, — if 
that this be the law, and that the exceptions which appear as such 
be merely interferences resulting from absence of natural power, 
— we should reasonably expect most benefit (cceteris paribus) from 
all measures, w^hatever their nature, which either acted by equa- 
Kzing the circulation, by determining, somehow or other, to the 
surfaces of the body, or by both in conjunction. Now, hitherto, 
the treatment of inflammation, though it involve many of the 
points which I have mentioned, has been, as it appears to me, con- 
ducted on a wrong principle ; it has begun at the wTong end, as it 
w^ere ; and even though it sometimes, in a practical sense, accord 
with true views, yet, where it does so, the views are not perceived ; 
and, though the many parts of the plan may be abstractedly right, 
yet (as has not unfrequently happened) they have arisen out of an 
hypothesis in itself false, or been altogether a matter of empiricism. 

It is necessary how^ever to premise, that, in discussing the 
treatment of inflammation, we for the present put those occurring 
on the surface of the body out of the (question ; because, w^iilst 
their treatment will sufficiently appear as an obvious induction 
from the general discussion, it yet involves certain details in its 
application, which will be more conveniently mentioned in connec- 
tion with the diseases w^hich they form ; the more important of 
which will be included in the present volume. 

We therefore, in discussing the treatment of inflammation in 
general, are supposed to refer to those more serious examples of it 
which involve internal parts of the body, and wiiich threaten the 
safety of the individual ; such as inflammation of the brain, the 



373 



various viscera, or tlie membranes which invest them, &c. ; and, if 
we refer to inflammation of a more local or visible character, it 
will be merely for purposes of illustration. 

Now, in all cases whatever, the first thing to be done is the 
placing the whole bodj, or any part of it, under circumstances least 
calculated either to maintain the causes or exasperate the actions 
or effects of inflammation ; and this may be regarded as the nega- 
tive treatment : such as absolute rest, that the circulation may not 
be excited by motion ; stopping the supply of blood by cutting off 
the supply of food ; emptying the bowels, — since, whatever the 
cause, a loaded condition of these viscera is found practically to 
give it additional force — and you will recollect I am not now 
talking of purging, but simply evacuating their contents by rapidly 
repeated doses of aperients, of which jalap, on account of its cele- 
rity and certainty, may be preferred ; and the washing the bowels 
out by copious injections of warm water. 

This should be thoroughly and efficiently done, not merely by 
injectiug a pint or a quart, or any other definite quantity, but, by 
means of an injecting syringe, as much should be thrown up as 
the patient can retain ; he will -then perhaps instantly void it ; and, 
if the quantity retained do not seem sufficient to have perx aded 
the lower bowels efficiently, the injection should be immediately 
repeated — a very few minutes sufficing for the whole operation. I 
can assure yoii this is very important. I have often seen cases 
wdiere the less efficient use of injections has done no good what- 
ever, but where the more effectual mode has been of the most un- 
expected benefit, although the syringe had been alike employed in 
both cases, and this not merely in inflammation — of which, more 
hereafter. I say, then, rest of the body, and of the part ; the 
avoidance of all excitement, bodily or mental ; great quietude, 
silence to the ear, subdued light or darkness for the eye, and so 
on ; absolute abstinence, and evacuation of the bowels ; — now, 
this I call the negative treatment. You will often find that, in 
cases not distinguishable from commencing inflammation, nothing 
more is required ; but these are not the cases you will have for 
the most part to treat, nor are they those to which I am about to 
refer. The inflammatory symptoms are progressing, and your 
positive and indeed very active treatment becomes alike necessary. 
Your treatment should be founded on clear views of the individual 
case, and be alike prompt and energetic ; you should have well 
considered the subject generally before hand. With this prepara- 



374 



tion, the rest is simple ; but, if you have to thiuk of things for the 
first tinie in the anxiety of a sick room, a person of good common 
understanding, out of the profession, will be more competent to 
treat a case than you will. 

The foregoing observations are general, and apply to all in- 
flammations ; but, in directing the other parts of the treatment, 
some points will be general, some will apply to particular cases. 
The first thing is to ascertain the seat of the malady ; to ascertain 
that inflammation is present. This is done by the observation of 
obvious phenomena (the symptoms) ; and here we see the element 
which morbid anatomy forms in pathological investigations ; for it is 
from the observation, in certain cases, of certain appearances after 
death, in connection with certain symptoms whilst living, that, in other 
cases, we infer similar results, and thus learn to recognize to what part 
the symptoms refer. Having then determined the seat, we next enquire 
the cause : and now you will recollect that the sympathetic influ- 
ence of any one organ may produce congestion, the necessary 
element of inflammation, in any other. Hence w^e now see how 
important is the practical result ; it being no less than this, that the 
seat of the inflammation, and the situation of its cause, may be 
very different ; and we further find indeed (local injuries excepted) 
that they are seldom the same. Another thing arising out of this 
is not less important ; viz. that the cause of the inflammation will 
generally be most auspiciously sought in the previous liistory or 
habits of the patient ; and this not only as regards habits of daily 
occurrence, but certain aberrations from these which, though only 
occasional, involve any series of repetitions. For the sake of ex- 
ample, a man's daily habits may be those of moderation ; but he 
may indulge in occasional excesses, even beyond the average accep- 
tation of that term : he may be, as regards daily habits, sedentary ; 
but may occasionally take lengthened or violent exercise : he may, 
as a daily matter, have regularity of his functions ; but occasional 
interruptions may have occurred, in which he has adopted particular 
remedies, and so on : or his recent habits may have, for months or 
even for years, been such that they are not perceptibly calculated 
to injure any organ or disturb any function, — yet, antecedently 
to a given period, they may have been very different ; so far indeed 
as, on the contrary, to have been characterized by any or every 
species of excess or irregularity. In other cases, the history may 
unfold the occurrence of some serious disorder at a former period, 
in regard to which a knowledge of the general nature of the reme- 



375 



dies employed will often be of the most essential service to our 
investigation ; and why I am so anxious to impress all this, is, that 
it is equally important in detecting the cause of other maladies, as 
it is often essential in eliciting the cause of inflammation. 

All this is equally necessary in cases which are called surgical, 
as it is in those usually termed medical ; since, even in inflamma- 
tion after accidents or injuries, if the danger result from the inflam- 
mation, it depends on the condition of the body ; which brings us 
to the same point, and renders the same kind of investigation 
necessary, in order to ascertain what that condition really is. All 
this is seldom sufficiently, if at all, done. I cannot perhaps better 
exemplify what I intend than by the relation of a case or two ; and, 
to shew the identity of plan as applicable to cases which usually 
fall under the care of the physician or surgeon respectively, cite 
one of each. 



CASE, USUALLY TERMED MEDICAL. 

I was called up one night to visit a gentleman in the country, 
concerning whom, when I arrived, I received the following account : 
He had been ailing about nine days ; but, until a day or two pre- 
vious, had been going about as usual. His ailment began by a 
sharp pain on the right side, referred to the situation of the eighth 
rib, near its greatest convexity. This pain had subsided, and 
again recurred ; and this had taken place when leeches and a blis- 
ter had been applied, as also when no such remedies had been em- 
ployed. The pain had also been accompanied by cough, which, 
however, did not subside altogether on the cessation of the pain. 
As the symptoms recurred, and even in an exacerbated form, he 
had been treated by aperients, and subsequently by saline medi- 
cine, containing small doses of one eighth of a grain of tartrate of 
antimony ; but the case did not seem to have been alleviated by 
the means employed ; on the contrary, the symptoms referring to 
the chest continued to increase, until inflammatory congestion there 
became so evident that his medical attendant, a very intelligent man, 
at once an active and cautious practitioner, thought it necessary no 
longer to postpone bleeding him : on his proposing this, however, the 
patient refused to submit to it, and desired them to send for me. 
When I arrived, I found the patient in the following condition : 
His countenance was anxious, and, towards the external angle of 



376 



the eye, a little haggard ; he could not be said to be delirious ; he 
knew me perfectly when I entered the room ; but he had become 
very intractable, and his countenance was very expressive of com- 
mencing cerebral disturbance ; and a little examination confirmed 
this impression. I had some difficulty in bringing to his recollec- 
tion that he had had any pain in the side ; but, after repeating the 
question three times, he pointed to what had been its seat : I could 
not find that he had any pain now^ He seemed also to have a 
striking unconsciousness of his situation. He complained of great 
oppression, however, about the chest ; and was coughing frequently, 
and expectorating considerable quantities of mucus, tinged by blood. 
His pulse was very excited, and 120 in a minute, but not hard. 
His heart was very noisy, and (on placing my ear to his chest) 
seemed to emit as loud a sound during its relaxation as during the 
contraction, whilst it was acting with great violence : yet he could 
breathe pretty freely w^hen desired to do so. His skin was moist ; 
his tongue moist also, but exceedingly vascular at the sides ; whilst 
the centre was coated with a deep yellow, and in parts with a very 
dark fur. His kidney ^vas not secreting copiously, nor very much 
otherwise, his urine having been chiefly voided during the evacua- 
tion of his bowels : that voided at other times was high-coloured. 
His bowels appeared exceedingly irritable ; the one eighth of a 
grain of tartrate of antimony having been followed by eighteen or 
twenty evacuations, these being almost entirely fluid. His whole 
condition impressed every one, his medical attendant and myself 
inclusive, with the idea that he was in great danger ; and whilst we 
both regarded it as a difficult case, we both agreed that it came 
more under the description of that case which is called typhoid 
pneumonia than anything else. Now, the previous history of the 
patient was, that he was a temperate but full liver ; that he eat 
meat commonly twice a day, and sometimes three times ; that he 
drank beer, and a few glasses of wine after dinner : that, on convi- 
vial occasions, he would do something more than this ; but that he 
was never what is usually understood by the word intemperate : 
that he took a good deal of exercise, writhout this being of a very 
violent kind : that he walked about a good deal daily, and rode on 
horseback occasionally : that he regarded himself as of a bilious 
habit, to correct which he occasionally took a little rhubarb and 
soda, as the leading indication was a sensation of acidity in the 
stomach ; but that his health was regarded as habitually perfect, 
though, for the last twelve months, he had now and then been sub- 



377 



ject to cough, of which he took httle or no notice. I should have 
mentioned that percussion of the chest elicited a dull sound on the 
superior part of the left side ; and that, for the last two years, he 
had been getting rather stouter than usual. 



OPINION. 



Now, looking to the chest, considering that he lived in good air, 
that he took exercise, that his chest was well formed, that he had 
never had any symptom of disorder there before, that there was no 
evidence of his having caught any cold, I did not think that the 
muse of the inflammatory disturbance referred to what was evi- 
dently the seat of it ; neither could I satisfactorily make out that 
liis stomach or bowels were the cause of it, since his bowels had 
acted copiously at all events, and were haUtuaUy regular, and his 
stomach had recently been subjected to no particular, nor indeed 
anything approaching to its ordinary, sources of excitement. To 
the skin I could refer nothing in the way of causation ; because, in 
the first place, there was no evidence of any injurious impression 
having been made on it ; and, secondly, it was acting exceedingly 
well : nor could I find any particular fault with the kidney ; since, 
the state of the skin being duly considered, it was difficult to make 
out more than that the urine was rather high-coloured. By this 
kind of negative reasoning, I arrived at the consideration of his 
liver. He had no pain nor tenderness there, certainly, nor in any 
other part of the abdomen ; and it was also true that the pain he 
had experienced might be referred perhaps to the chest, with quite 
as much probability, to say the least of it, as to the liver : but then 
1 thought both his temperament and habits such as frequently led 
to disorder of this viscus; that, although his symptoms did not 
evince any inflammatory action about the liver, they presented 
nothing inconsistent with a plethoric condition of the organ. Again, 
his bowels, though acting so profusely, shewed no profuse, nor even 
ordinary, secretion of bile ; whilst, on the other hand, I knew that 
congestion of the liver was at least competent to disturb the organs 
of the chest. I therefore said to the medical attendant — first, that 
I thought the real cause of the mischief would be most rationally re- 
ferred to the liver ; and, secondly, that I should act (he agreeing) en- 
tirely on that opinion, even for the moment at least, to the exclusion 
of bleeding ; that, although I spoke with that caution which became a 



378 

knowledge of our difficulty, yet mj opinion was, as an opinion, de- 
cided ; that his getting better, however (should that fortunately 
happen), would, of itself, by no means satisfy me of the correctness 
of my opinion, unless he did so simultaneously with discharges of 
morbid or increased biliary secretion. The medical attendant 
seemed pleased with the rigour of the test I proposed ; but appeared 
at first somewhat unprepared for such views : however, he was, as 
I said, an intelligent man ; he evidently thought for himself ; and, 
on my going over the reasoning which I have already stated, he 
agreed that there was something very feasible in my views, and, in 
short, seemed at length to participate in them. We accordingly 
acted on them in the following manner : We gave him three grams 
of calomel every tln^ee hours, and three quarters of a grain of 
opium with it, on account of the great irritability of his bowels. 
If the bowels bore this well, the opium was to be gradually dimi- 
nished ; and, to avoid irritation of the bowels still further, as also 
from my experience of its effect in promoting perspiration, we di- 
rected efficient enemata of warm water or gruel to be given, night 
and morning, with as little fatigue to the patient as possible. 

I appointed to see Mm again after about thirty- six hours ; the 
understanding being, that I was to be sent for immediately, if any- 
thing went wrong. At the end of this period, I again saw our pa- 
tient ; and the result was very gratifying. He had lost all oppres- 
sion about the chest ; the pulse w^as ninety- six, and rather feeble ; 
the tongue improved ; he had had a good night ; the bowels had 
acted from the pill, discharging a quantity of biliary secretion, 
dark, foetid, and, as the patient said, " like bird-lime ;" the cerebral 
disturbance was gone. He was allowed to take minute quantities 
of beef tea, with morsels of toasted bread, for which he felt de- 
cided inclination. We now diminished the dose of calomel and 
opium ; but, on relinquishing it, he had a slight return of his sym- 
ptoms, which, however, were again relieved by the same ineasure, 
except that now the opium was diminished to one-fourth of a grain. 
His recovery was otherwise uniformly progressive ; his resumption 
of ordinary diet being extremely gradual. The calomel w^as gradu- 
ally diminished, and an occasional blue pill, when the secretions 
suggested it, given at night, — being the only medicine, except, as he 
got better, some infusion of columba. 

Now this case was very striking, as testing the general practice 
in such a case. I mentioned it, wliilst under treatment, to different 
medical men ; they all, with one exception, said you must bleed 



379 



tlie patient. One gentleman, however, seemed to appreciate the cir- 
cumstances : "Ah!" said he, "it is a bad case, sir; you will not 
save him." I may observe that, even when he was so far better as 
to be considered (imprudence apart) out of danger, nothing could 
convince a relative that he would recover, as she said she had seen 
his father and his brother die with precisely the same symptoms. 

Now, how valuable this case is ! The bleeding, to say no more 
of it, would have been unnecessary ; but, when we consider that 
his state was already one of excitement, which was followed by 
great debility, the clear resemblance it bore to that state which so 
often terminates in typhus, we should perhaps not say too much, in 
assuming that it would have been prejudicial. But, further, the 
success in this case was in consequence of similar modes of exami- 
nation having previously furnished me with similar information in 
cases, not perhaps identical in all respects, but analogous in their 
essential characters. I will now state another case, which, as re- 
gards the order of the symptoms, would be termed medical, but 
which involved surgical matters also. 

CASES OF FEVER, WITH THE SUPERVENTION OF 
ERYSIPELAS. 

A man-servant in a family, who was very fond of indulging in 
eating and drinking, but whose organs for the disposal of such 
matters were often deranged by the quantity of work given them, 
was frequently ill in consequence; and I had, on several occasions, 
put him right by prescribing an aperient, with low diet ; but, in 
spite of my repeated warnings and his own fears (for he was always 
exceedingly alarmed when ill), he continued to indulge ; and even 
began to do so, on one occasion, the very day after the cessation of 
slight cholera, not Asiatic, but still occurring at the time that the 
Asiatic cholera was prevalent. At length, after an unusual indul- 
gence, even with him, he was taken ill, with cold shivering, folio w^ed 
by heat and excitement, with red and furred tongue. I saw him in 
the evening, and gave him an emetic and a purge ; and the next 
day he was a great deal better ; but he complained of soreness on 
the right side of his chest. At this time, the family having some 
of their other domestics ill, it was proposed to send this man to an 
hospital, whither he went the same day. As I was going that way 
tw^o or three days afterwards, I called at the hospital to see him ; 



380 



aud I shall never forget his appearance. When directed to his bed, 
I reallj did not recognize him, and was going to another bed, 
when a faint smile of recognition shewed me that the face so 
changed was really that of the patient I sought. His countenance 
was haggard, the cheeks wan, their bones very prominent, his 
tongue very foul and dark, pulse rapid, and in such a state that I 
at once made up my mind that he could not possibly recover. 
But, as I could not imderstand the case, having seen him exactly 
in similar conditions to that in which he went into the hospital, and 
from the same cause, I waited on the apothecary, the physician not 
being there, to learn more of the case. On expressing my diffi- 
culty in understanding so rapid a decline, &c. the apothecary, a 
man exceedingly well informed, said, " I suppose you know that 
he has been bled ?'' " Bled !" replied I ; " for what reason ?" I 
now saw that the apothecary neither understood the reason, nor 
agTeed in the propriety, of this measure ; but still he did not ap- 
pear fully to agree with me as to its consequence ; for, on my 
adding that the man would certainly not recover, he rejoined, "1 hope 
things are not so bad as that either." Now the tenderness of the 
side, of which the man had complained, developed itself into ery- 
sipelas, for which he had been bled to twenty ounces : incisions 
were made, the erysipelas having got rapidly worse instead of 
better, the incisions being made with my own concurrence. In 
the mean time, the rapid failure of the man's powers, after the 
bleeding, put all resources of this kind out of the question ; and, 
in spite of every care, attention, and support from wine, &c. he 
sank and died. 

In relation to the effect of the bleeding, it was very important 
to know whether it had subdued his pow-ers, as the progress of the 
case and the nervous system of the patient seemed to shew, by a 
direct agency, or whether it had acted on a system previously 
weakened by any serious affection of any organ. The gentleman 
I have already alluded to examined the body ; but no disease of 
any organ was discoverable ; whilst the whole case, as well as the 
erysipelas, evinced mere want of power ; for I should have men- 
tioned, that, whilst the erysipelas had not extended, there was not 
the slightest evidence of repair. This was a case in which, had 
the real cause of the disturbance, including the inflammatory 
localization of it in erysipelas, been made the basis of treatment, I 
have not the slightest doubt but that the man would have reco- 
vered ; since, on many occasions, his recovery Irom similar condi- 



381 



tions depended on such a mode of treatment ; whilst the benefit 
resulting, for a few hours, from his treatment previous to his leav- 
ing his home, is perfectly consistent with this view of the subject. 
The cause of the malady was essentially functional disturbance of 
his digestive organs ; the remedy ought to have been its correction, 
which, from what had happened on Ibrmer occasions, and even in 
the one in question, so far as the case w^as so treated, would pro- 
bably have been safely effected by aperients, abstinence, and per- 
haps small doses of tartrate of antimony, or other medicines of 
that class. In further illustration of these views, and modulating, 
as it were, by degrees, from medical cases (so called), though a 
mixed case, into one that would be termed surgical, I will mention 
the following, because it is remarkably analogous to the first case, 
although the disease commenced by actions for which people usually 
consult surgeons*. 



CASE. 

William Smith, set. sixty-five, by occupation a hackney coach- 
man, was admitted a patient of the Finsbury Dispensary, with a 
very curious affection of the right arm, which had existed several 
years, and which presented the follow^ing appearance. The arm 
was considerably larger than the other, and its natural symmetry 
further disfigured by great irregularity of form, being much larger 
in some parts than others, and presenting in different parts a series 
of openings, through w^hich a thin, unhealthy discharge issued, 
its quantity varying at different periods ; and shewing al.^o that 
some openings had healed, whilst others had formed : the manner 
in which the openings formed being as follows : — first, an elevation 
of the integuments would take place, which was not discoloured ; 
but presented an appearance best conveyed by saying that it was 
tuberculated rather than inflammatory. At first these ulcerations 
were firm, then they would become soft, and then a little inflam- 
mation, accompanied by its more usual characteristics, viz. heat, 
redness, &c. would be established on oiie point ; and this bursting, 
matter of the description which I have mentioned would be dis- 

* This case was to me the more impressive from my having under my care, at 
the same time, a young gentleman whose case was an exact parallel, except that 
the excitement, both local and general, was much greater, but who was not bled, 
and who did perfectly well. 



382 



charged. The whole limb was so strikingly that of a case of 
diseased bone, that at first I had no other idea ; but I wished him 
to come to my house, in order to investigate the causes of his 
complaint more narrowly ; since many circumstances convinced me 
that the man spoke truth, when he asserted that he had always 
been particularly temperate, and not at all addicted to the mode of 
living so usual amongst men who follow his avocation. When he 
came to my house 1 examined his limb with great care ; and al- 
though some difficulty resulted from tracing the bones through 
much firm, misshapen, and irregular thickening, the result of various 
deposition in the cellular tissue, — yet I convinced myself that the 
bones had undergone no change ; and began to investigate the 
case, under the idea that it might be one of diseased absorbents. 
The examination of the case soon convinced me that this was not im- 
probable, and the subsequent experience of it confirmed the opinion. 

Amongst other circumstances, there were two firm, cord-like 
lines, felt deep on the inner side of his arm, as far as the axilla, 
without any discolouration or tenderness : pressure on these chords 
communicated an elastic feel, and all the sensations of a vein, sup- 
posing its coats tense and thickened : both these disappeared under 
treatment. This part of the case I shall have occasion to talk of 
hereafter : 1 will therefore only add here that it had got much 
better, and was altogether progressing favourably under treatment 
directed chiefly to the improvement of his health ; so that now w^e 
only saw him occasionally ; and all this under very difficult cir- 
circumstances, since he followed his employment all the time ; 
w^hen he sent to request that he might be visited at home, as he 
was very ill. When seen, he was labouring under nervous excite- 
ment ; he complained of great pain and tenderness, both in his 
limbs and his abdomen ; the tenderness being most remarkable in 
the region of the liver, extending low down on the right side, and 
across to the middle of the lower part of the abdomen. He did 
not know to what cause to attribute his present ailment ; but a 
horse had trodden on his foot about a week before, and erysipelas 
appeared to have supervened, with red lines running fi-om the in- 
flamed part up the limb, indicating inflamed absorbents ; tongue 
furred ; bowels costive ; urine scanty and high-coloured ; pulse 
frequent and sharp, indicative of great excitement, but little power ; 
motions dark. He was ordered to take nothing but w^eak gruel ; 
His bowels were opened by half a grain of calomel and eight grains 
of jalap, given every three hours till it operated ; and after that he 



383 



was to take two grains of calomel and one-sixteenth of a grain of 
tartrate of antimony every three hours. This was on September 
25th-26th ; bowels freely opened, motions still dark, symptoms 
much the same : 27th, no improvement, bowels open, motions 
still dark, urine scanty, no particular alteration in the foot ; eight 
leeches are ordered to be applied to it ; a saline aperient with half 
a drachm of vin. colchici every lour hours : 28th, rather better, 
pain not so violent, urine more copious, inflammation of the foot 
diminished, bowels freely open : 29th, pains less, but feels weak, 
pulse frequent and feeble ; to omit the mixture and take infusion 
of bark, with ten drops of dilute sulphuric acid, three times a day ; 
no appetite, but allowed to take small quantities of beef-tea fre- 
quently : 30th, still weaker, face swollen, eye-lids and side of the 
nose occupied by erysipelatous inflammation* ; the acid to be dis- 
continued, and five grains of the subcarbonate of amm.onia to be 
substituted. October 1st, getting better; to take a glass of port 
wine, and to repeat it in two or three hours if indicated : 2nd, the 
wine, although he only took it once, was followed by a violent pain 
in the stomach ; the pulse to day is full, frequent, and bounding ; 
tongue dry and furred ; the skin not w^ithout perspiration, but the 
motions still dark and very offensive ; the decoction of bark to be 
given instead of the infusion, and the acid resumed instead of the 
subcarbonate of ammonia ; hydr. c. creta gr. viii to night, and to 
be repeated in the morning : 3rd, much the same ; complains of 
pain and tenderness in the side ; skin hot and dry ; tongue, how- 
ever, moist, and, although furred, is not brown ; and he had two 
evacuations of a yellow colour, and not offensive ; to take pil. hy- 
drargyri gr. iv, ipecac, gr. ii, extract of henbane gr. v, to-night and 
to-morrow morning : 4th, better ; one motion, scanty but yellow. 

I need not pursue this case to its termination in detail ; it is sufh- 
cient to observe, that we now decided, that if we could support liis 
strength, we should obtain most benefit by acting more decidedly 
on his liver ; and, therefore, whilst he was allowed any little sup- 
port which he fancied, which was very trifling, we gave him calo- 
mel, with small additions of opium, in repeated doses. The effect 
of this was, that tw^o or three daily evacuations were produced, 
which were flrst dark and offensive, but subsequently of a healthy 
colour. The tongue, which hitherto had been coated with a fur 

* His breathing, which had been all along oppressed, now became very labori- 
ous, indicating accumulation in the bronchi, which he appeared too weak to 
discharge. 



381 



almost black, now became clean ; the appetite returned, and the 
diet having been progressively increased from small quantities of 
beef- tea, with sparing, though frequent allowances of wine, to plain 
boiled mutton, exclusive of fat, grease, &c. : the patient recovered. 

Now, the foregoing case is very instructive : you see — bleeding 
apart, which a careful examination of the case shewed to be a very 
doubtful measure, and which I am persuaded would have sunk him — 
that the treatment was conducted with an especial view to correct that 
organ which was most prominently in fault ; but yet, with an endea- 
vour to assist this effect, by such combined appeals to the sympathetic 
influences of other organs as the case suggested : and that, not- 
withstanding the appearance of some small degree of success in 
these objects, his powers began to fail; that bark, wine, and am- 
monia were substituted ; in fact, that the treatment involved, though 
perhaps with more specific objects, all those circumstances which 
really take place in the ordinary and admitted treatment of such 
cases. You however observe, that the man w^as at length in a 
position strikingly analogous to the first case : there was the same 
state of nervous system, the same state of chest, the same nervous 
excitement, the same indication of debility ; but ail in an exagge- 
rated form, and in a much older man ; and that we were driven at 
length, by the failure of all other measures, to restrict ourselves, in 
the end, to the more powerful adoption of that of which the com- 
mencement of the treatment formed a type, and which were from 
choice adopted in the first-mentioned case from the beginning, and 
with the same success. I certainly never saw a patient recover 
before from the same condition in which this man was ; and al- 
though I apply this observation more emphatically to the latter 
part of his case, yet it is equally true, with regard to the excessive 
nervous excitement and the accompanying debility, to all other 
periods of it. 

Now we shall have to talk of erysipelas again ; and in the 
mean time you will say, perhaps, that you should like to have an 
example illustrating the effect of the treatment of inflammation, 
founded on the connection of the disturbance of the general sys- 
tem, or with any organ, in which the inflammation was, in common 
phraseology, more pure ; that is, presenting the characters of ordi- 
nary inflammation as distinguishable from erysipelas, or any other 
of its multiform varieties. Tn the present state of medical opinion, 
this is a reasonable requisition. I will therefore give you an ex- 
ample of this ; but it is necessary to premise that this is difiicult, 



385 



not from want of evidence as regards the effect of treatment, but 
from the fact, that those inflammations to which we refer, when 
discussing the treatment generally, are out of sight ; wherefore we 
cannot say with certainty whether they may have what we call 
the characters of pure inflammation or not. For if we take in- 
flammation of the peritonseum or pleura, we cannot see that those 
external characters by which we distinguish erysipelas and other 
forms, are those of pure inflammation, because we cannot see 
them at all. And if we allow the inferences deducible from the 
observation on dead bodies to be applied to the solution of similar 
phenomena of symptoms as exhibited on the living, we find the 
appearances corresponding much more nearly with erysipelas, or at 
least quite as much as they do with what we call pure inflamma- 
tion. Where, for example, do we find, in pure inflammation, that 
rapid or violent extension of it, which not only takes place in, but is 
so striking a characteristic of inflammation of, the pleura and peri- 
tonaeum ; and to which state shall we liken those irregular and abor- 
tive attempts at adhesion and circumscription of inflammatory action 
by which inflammation of these membranes is doubtless also cha- 
racterized ? As regards the extension, they are exactly analogous 
to erysipelas ; whilst in the manner of their adhesions, in these 
dangerous cases, they are mere shadowings of the adhesive process 
as we see it bounding pure inflammations : and this, be it remem- 
bered, notwithstanding the characteristic disposition which these 
parts have to such adhesion. We see these healthy adhesions in 
wounds, and in certain cases of hernia, as familiar occurrences ; 
but then they have been essentially reparative in successful pro- 
cesses, induced by local injury, — manifestations of natu^lly ex- 
cited powers ; and not the productions of functional or organic 
disorders. To give you, then, even what you require, or the 
nearest approximation to pure inflammation, if there indeed be 
such a thing, I must take the eye ; because here you can observe, 
at least, what approximation there is to our notions of pure in- 
flammation (occurring without mechanical injury), and you can 
watch its influence, under treatment, with a precision obviously 
impossible in the cavities, or in the concealed viscera of the 
body. 

Now as one of the first circumstances wliich led me to think 
on what might be the real causes of inflammation may possibly 
have a corresponding eflect on other minds, I will, in the first place, 
state, that, many years ago, there was a patient in St. Bartholo- 

c c 



386 



mew's Hospital with an apparently pure inflammation of the eye, 
which, although pretty actively treated in the usual manner, did not 
seem to yield to the measures employed. I have the most vivid 
recollection of this case ; and, were I a draughtsman, I fancy 
I could draw a pretty faithful sketch of it at the present moment. 
It was not distinguishable from common inflammation of the con- 
junctiva ; but, as I have said, it did not yield to the usual anti- 
inflammatory treatment. The bowels being costive, the patient 
took an active aperient, which produced, during the night (probably 
when warm in bed, and the skin favourably circumstanced), pro- 
fuse discharges from the bowels ; but what followed ? why, the 
next day there was scarcely a vestige of inflammation, Now this 
was instituted, you observe, with nothing more than a general inten- 
tion ; and what the particular condition of the nervous system 
generally might have been I know not ; but I never forgot the fact, 
nor ceased, at intervals, to recur to its consideration. I will now 
tell you another 

CASE. 

A man applied at the Dispensary to be treated on account of 
an active inflammation of the eye. The conjunctiva was very 
vascular, and slightly raised from off the subjacent membrane (the 
sclerotica), though not so much as to make the cornea appear as if 
situated in a depression, as m the state which we term chemosis. 
There were an ulcer of the cornea and opacity of the inferior por- 
tion of the membrane. He had pain extending to the globe ; in- 
tolerance of light : his bowels were regular; in fact, rather inclining 
to a relaxed condition : his pulse full and strong, but irregular, and 
intermitted occasionally : his tongue exceedingly furred ; but I do 
not recollect that he complained of deficient appetite : his tongue 
was, notwithstanding, remarkably coated : and, on examining all 
the features of the case, it was in no respect difi"erent from pure 
inflammation. I was disposed to think that his aversion to, or in- 
tolerance of, light was hardly so great as the degree of inflamma- 
tion might have led me to expect. As I had a very good opportu- 
nity of watching the case, through the assistance of Mr. Leigh, I 
was determined to try what influence I could produce by measures 
directed to what I believed to be a competent cause of the inflam- 
mation, and which was, at all e\^ents, a very obvious indication of 
disorder ; viz. the stomach, as indicated by the tongue. The treat- 



387 



ment was therefore entirely directed on tliis principle ; and I 
requested Mr. Leigh to visit the case at short intervals, directing 
him, should the inflammation of the eye appear to make any pro- 
gress, at once to institute the ordinary treatment of inflammation, 
in the most active sense of the term ; but, in the mean time, to 
keep the reasoning clear, even leeches were interdicted. I pre- 
scribed the man an emetic ; and this was to be repeated in the 
morning, subject to Mr. Leigh's observation eliciting no change 
contra-indicating it. The emetic operated, and was repeated, 
operating well on both occasions ; and the eye improved so far that 
the pain was much mitigated ; but the inflammatory appearances 
were not perceptibly altered; certainly, however, they were no 
worse. As the pain subsided, however, the intolerance of light 
seemed rather to have increased. His bowels continued open ; 
but his stools, having been observed, were reported to be light- 
coloured, and he was ordered a pill, at night, of three grains of 
calomel, with fifteen of the extract of colocynth. The next day, 
the bowels had acted, the motions still light, but the urine high- 
coloured ; the eye was still better, the vascularity of the conjunc- 
tiva less, and the iris, concerning which we had been anxious, not 
getting a good view of it through the opaque cornea, was now seen 
to dilate freely on the application of belladonna. This man now 
took %o other medicine than a weak solution of sulphate of magne- 
sia, withone eighth of a grain of tartrate of antimony, every 
morning ; the inflammation gradually retiring, and the ulcer 
healing : so that, having been altogether fourteen days under care, 
he was discharged well. His diet, at first, was simply gruel and 
toasted bread ; and, though sparing throughout, yet a little broth 
or beef-tea was allowed as the inflammation retired. But you ob- 
serve that he lost no blood, and that his treatment consisted en- 
tirely of medicines directed to correct the obvious disorder of his 
stomach primarily, and then his liver ; the remainder being merely 
an aperient, combining one eighth of a grain of tartrate of anti- 
mony, with a view to promote gentle perspiration. I believe also 
that his stools lost their light colour; but, as the state of the 
bowels at the conclusion is only mentioned generally in the notes, 
I cannot state that the fact was so. 

The following case is also interesting, as shewing that kind of 
link which connects sympathetic functional disorder with the subse- 
quent induction of inflammation. 

Isabella Cranmer, aged thirteen, was admitted into the Dispen- 
c c 2 



388 



sary with pain in the right eye, accompanied bj total loss of sight. 
She described the pain as very severe, and shooting to the back 
part of the head. The pupil was somewhat contracted, and the 
iris tarnished in brilliancy. There was intolerance of light, with 
disposition to keep the eye shut. The tongue was farred; the 
bowels costive ; the secretions reputed to be discoloured. She was 
ordered pil. aloet. gr. x, saponis, gr. v, every four hours, until the 
bowels should be freely opened. The bowels acted freely, and the 
eye immediately improved ; that is to say, the pain became much 
mitigated, and there was even very slight degree of vision. The 
case continued to improve without interruption until the eleventh 
day, when there was a relapse of the symptoms. We could not 
disco\'er the cause of this relapse ; but a careful enquiry elicited 
that the kidney was not performing its usual duty, the quantity of 
urine being small : wherefore, regarding this as a hkely channel for 
acting sympathetically on any other organ that might be disor- 
dered, we simply ordered her some nitrate of potash as a diuretic. 
This produced no increase in the urinary secretion; but the bowels 
acted this morning, the evacuation being of various colours, and 
containing a number of small worms. We now resumed the pills 
of aloes and soap : her secretions became of a more natural colour, 
and more worms were voided She now got well without further 
interruption, having voided no worms for ten days previous to her 
discharge ; her vision gradually but perfectly returning, and the 
pain and other symptoms pointiug to deep-seated inflammation 
ha\dng all subsided. In the course of the treatment, INIr. Leigh 
recognized the case as having been under my care about four years 
previously, and being, on that occasion, inflammation of the con- 
junctiva and cornea, with hypopyon and iritis, and having been 
then also treated by removing what appeared to be the real causes 
of the inflammation. 

The following is a summarj- of the notes of her case, taken at 
that period ; she being then nine years of age. She applied with 
an affection of the eye, presenting the appearance of catarrhal 
ophthalmia, the conjunctiva very v ascular, and red vessels extending 
on the cornea ; pain not severe ; little intolerance of light ; ab- 
domen tumid ; al\dne functions irregnilar. Hyd. cum creta, and 
rhubarb ; low diet. The eye to be covered with a green shade ; 
poppy fomentations and leeches to the eye-lid. At her next visit, 
which was not till six days afterwards, inflammation much aug- 
mented ; states that she became much w^orse two days since : there 



389 



is opacity of tliG cornea, and matter in the anterior chamber — 
hypopyon. (This exemplifies the difficulties we have to encounter 
in dispensary practice, from the irregularity of patients in attend- 
ing, or even sending reports, in order that they may be visited.) 
The eye was now treated by leeches and calomel, gr. ii. ipecac, 
gr. i. ter die ; blisters behind the ears ; and the extract of bella- 
donna on the brow, in the usual manner, as the iris looked in a 
doubtfal condition. To these were added aperients, when neces- 
sary. The effect of these measures was so far good, that the mat- 
ter in the anterior chamber became, in some degree, absorbed, and 
the cornea more clear; but, although the mouth was affected by the 
mineral, no further improvement was effected by it ; aad she could 
distinguish nothing with the affected eye. Lymph also became 
effused on the iris. Besides this, the other eye now became 
affected ; w^hen the circumstances pointing to the alimentary canal 
(I mean the tumid condition of the abdomen and the disposition to 
costiveness) determined me to direct our measures exclusively to 
those viscera. She was therefore ordered one grain of calomel and 
five of the aloetic pill every three hours, until the bowels were 
freely evacuated. This object having been effected, the eye in- 
stantly began to improve, and so rapidly, that she could at once 
distinguish some objects. The bowels were now kept open by a 
repetition of the pill night and morning. The eye continued to 
progress favourably without interruption; the cornea becoming 
clear, and vision completely restored. 

We here see the ordinary treatment of inflammation, pretty 
actively pursued, considering the child w^as only nine years of age, 
producing some improvement, but without the functions of the or- 
gan being restored : we also see that, simultaneously with a free 
evacuation of the bowels, the case improved progressively, until 
the inflammation was subdued and sight completely restored. 

Here is another case, in w^iich, although I perceive by the 
notes that twelve leeches were employed, still it seems reasonable 
to infer that such a measure had not much influence on the treat- 
ment. I select it, however, because in other respects it appears 
instructive. 

Samuel Oliver, an unhealthy-looking young man, with a 
withered arm, the sequence, he says, of an attack of paralysis 
when he was a boy, applied on account of an inflammation in 
his right eye. The conjuactiva is much inflamed ; and there" is 
partial opacity, with a deep ulcer in the cornea. He has had a 



390 



good deal of pain, shooting to the back part of his head ; the 
aqueous humour is turbid ; and the brilliancy of the iris is ob- 
scured, but its colour is not perceptibly changed. The tongue is 
much furred ; the bowels costive ; the pulse feeble. He says that 
his eye has been gradually getting worse for a week past. He was 
ordered the extract of belladonna, to be applied in the usual man- 
ner ; small doses of calomel and jalap to be given at short inter- 
vals until the bowels are opened, and then to take a weak solution 
of salts in mint-water, with a little tincture of lavender, twice a 
day ; twelve leeches to be applied to the eye, and a tartar- emetic 
plaister to the nape of the neck ; with gruel diet. Four days after 
this, the eye was much better ; the inflammation rapidly declining, 
and the ulcer of the cornea healing, although there is still a red 
vessel seen in the centre of the ulcer ; the pain in the head and 
eye quite gone ; the bowels open and regular ; the tongue much 
improved ; and the cornea clear, except in the immediate vicinity 
of the ulcer. No further measures were employed, except the con- 
tinuance of the aperient mixture, to keep the bowels regular. In 
about ten days after this, he was discharged quite well. 

The reasoning of this case is not quite clear, in consequence of 
the simultaneous employment of so many measures, of which I 
so much complain in the practice of others. What might have in- 
duced this I now forget ; but, after making all reasonable allow- 
ance for the leeches, I think they at least can have had little to do 
with the relief of the case ; for, if we attack such a case by deple- 
tion, we shall find that we might as w^ell do nothing as be satisfied 
with that afforded by leeches ; whilst that determination to the sur- 
face occasioned by the tartar-emetic ointment is much too slow to 
be relied on in acute cases. From what I know of such matters, I 
think it probable that both the one and the other had more refer- 
ence to some concomitant condition, which I have not recorded, 
than to the eye per se, the affection of w^hich was combated by 
attention to the prevailing disorder of function — viz. costive bow- 
els ; for, to those who may be inclined to think that the leeches, or 
even the tartar-emetic, exerted much influence, I may observe, 
that I would not advise them to place much reliance on such mea- 
sures ; because, if inflammation, such as occurred in this case, be 
combated by such, they must be instituted, as I shall have occasion 
to remark hereafter, in a very different form and with a much 
greater activity. 

In relation to the foregoing case, 1 would also^bserve, that the 



391 



difficulties in dispensary practice are of a kind of which the prac- 
tice in an hospital affords no example. In cases where you have 
any doubt, you are often obliged to generalize your treatment, in a 
manner that is wholly destructive of close reasoning ; because the 
irregularity of the patient often aflPords you no reasonable chance of 
doing as you would desire in conducting the treatment. I have, 
however, of late, since the appointment of Mr. Leigh to the Dis- 
pensary, had more time to select cases, and to conduct the treat- 
ment in a manner which keeps the reasoning close, and w^hich 
might be done in every case in an hospital, to the great advantage 
of science. 

One more case I will give very briefly. A young w^oman, 
many years ago, was affected by gonorrhoeal ophthalmia, having 
been previously subject to repeated attacks of ophthalmic inflam- 
mation of a catarrhal form. She recovered perfectly as to one eye, 
— the pupil of the other having become closed, under this dan- 
gerous inflammation (I mean the gonorrhoeal), — by very copious 
blood-letting and severe salivation, under my care : but I need say 
no more of this part of her history, as I gave the case to Mr. 
Lawrence, and it will be found in his Treatise on V^enereal Dis- 
eases of the Eye. This was about fourteen years ago. Since that 
period, she has been occasionally subject to inflammation of the eye, 
which has been subdued by what always appears to be the correction 
of the cause of these occurrences ; namely, a functional disorder of the 
liver and bowels, the latter more particularly. She is incautious in 
her diet, and habitually negligent of her bowels. On all occasions, 
the ordinary treatment of inflammation has been first instituted ; 
and that exclusive direction of it to the disturbed organ, on the 
sympathetic influence of which the inflammation appeared to de- 
pend, has been a superposition on the failure of the common anti- 
inflammatory treatment to arrest the inflammatory action. The 
only part, however, of her history, which I shall here more particu- 
larly mention, refers to an attack of a very different kind, as re- 
garded its seat and the symptoms by which it was accompanied. 
She was attacked by a sort of stupor, which gradually increased to 
a state nearly approaching to insensibility. For this she was at 
first prescribed leeches behind the ears, aperients, and low diet, 
with some benefit ; but, as she again committed imprudences in 
diet, — one of these being that she ate a considerable quantity of 
very greasy pudding, — the stupor recurred, and soon assumed the 
form of muttering delirium, with difficulty of breathing and 



392 



oppression of the chest, so great as to threaten y speedy and fatal 
termination. I was now requested, by the gentleman who was 
attending her, to see her. I found her in the state already de- 
scribed. She could not be said to be absolutely insensible ; but 
she was roused with great difficulty ; and, though I succeeded in 
obtaining, after repeated efforts, answers to a question or two, yet 
the answers were rather incoherent. Her respiration was exceed- 
ingly laborious, and with such loud crepitation as made me fear 
that the slightest further declension of power w^ould be necessarily 
followed by suffocation. Her pulse was frequent, but neither hard 
nor full ; the tongue brownish-yellow. 

I regarded this as a mixed case. I had no idea that the real 
cause of the disturbance was either in the brain or chest ; and the 
history of the case readily enough suggested the bowels ; but then 
her bowels had been opened ; and it might be the liver, or even the 
uterus ; for, previously to this attack, she had been irregular. As 
for bleeding, notwithstanding the evidence of inflammatory action 
going on in the chest, &c. her general state seemed to indicate a 
debility, rendering that a very doubtful measure ; and the pulse 
seemed to contra-indicate it. I was therefore resolved to try 
what freely evacuating her bowels would do ; flrst, from my know- 
ledge of her besetting peculiarities ; and, secondly, because I had 
so often seen exactly the same kind of tongue in connection with 
loaded bowels, that I regarded the appearances on her tongue as 
strengthening the idea which her known peculiarities suggested. 
Besides this, although she had had, as I was informed, pain in the 
hypochondrium, and dark stools, yet both these symptoms had re- 
tired previously to my seeing her. 

It was difficult, of course, to decide what organ was chiefly 
wrong ; but I decided on ministering to the bowels, for the reasons 
which I have stated, and also because I knew that, if I acted on 
the bowels, I should be more certain of exciting the liver through 
them, if the liver were the part now wrong, than I should be if I 
excited the bow^els by remedies solely directed to the liver, should 
my supposition prove the correct one. I therefore gave her conti- 
nued and graduated doses of aperient medicines, combined with 
enemata of warm water. She had also a tartar- emetic plaister ap- 
plied to her chest. The measures addressed to her bowels produced 
copious evacuations ; her tongue began to clean ; the oppression of 
the chest subsided ; and she got well without any further measures, 
except substituting, for the copious evacuation of the bovrels, such 



393 



modified means as procured the daily regularity of tlieir 
functions. 

I could go on relating cases of this kind ; that is, of inflamma- 
tion and inflammatory action subdued by striking at the root of 
their causation, both where the usual treatment had failed, and 
where it had not been instituted. 

Now I have mentioned these cases in illustration of the true 
principles on which inflammation should be treated ; that is, by en- 
quiring into those states of the body generally, or that of particular 
organs, which are competent to produce inflammation by deter- 
mining blood to other parts, in conformity with that power of 
which the phenomena of sympathy demonstrates the existence. 
In relieving the function of any organ labouring under inflamma- 
tion, where we cannot strictly give it rest, a due regard to those 
organs which may hold a general sympathy with it, or a particular 
one in community or concurrence of function, will be of great ser- 
vice to you. In this way, you may relieve the skin by the kidney, 
or kidney by the skin ; or the lungs by the skin ; the stomach by 
the liver or skin ; or vice versd^ as has been already dwelt on in 
connection with " Sympathy." All these principles require peculiar 
plans in particular cases, and involve a very close examination 
both as to the previous history of the patient and as to any indis- 
position imder which he may have laboured, however trifling, es- 
pecially if he can tell you what happened in regard to any organ 
when he became relieved. I admit this to be laborious; but there 
is no royal road to the interpretation of nature. Her operations 
must be studied to be understood ; and nothing is more important 
than the recollection that the ^ea^ of inflammation ma}' be in one organ 
whilst its cause is in another. A man who examines a piece of 
mechanism is often obliged to spend much time before he can dis- 
cover the cause of its imperfection ; and how can we expect that a 
rapid survey of a few minutes can suffice to ascertain the condition 
of so complicated a machine as the human body. You may be 
assured it is impracticable : there is no trickery in real science : 
and, although an assumption of quickness may deceive the many 
into an idea of the talents of an individual, — yet that pretension to 
celerity of decision in many cases of inflammation is not only in- 
consistent with any chance of discovering the causes of the malady, 
but it is the merest quackery, which a very little sound knowledge, 
instead of the trash taught them by empiricism, would enable the 
public to meet by its just reward. 



394 



To return to our subject : I must now observe that the treat- 
ment of inflammation, with a view to the discovery and removal 
of the real cause of the malady, is yet in its infancy ; and a num- 
ber of circumstances oblige us to substitute other and more ordinary 
modes of proceeding. These circumstances are chiefly as follow : 
In practice, and especially in public practice — the only suflicient 
field commonly afl'orded to any one individual for investigations 
into the nature of disease, — we are often called on to treat a 
case when the inflammation has become so established that it is 
already threatening the destruction of the organ, as in the eye, or 
the life of the individual through the suspension of the functions 
of some organ essential to vitality. 

Then again, in other cases, there may be either no circum- 
stances which point with sufficient clearness to the real cause of 
the malady to enable us to see, with auy approximation to certainty, 
the organ or organs to which this cause may refer ; and, again, 
such circumstances may really be afforded to us, and yet a rea- 
sonable caution may induce us to discard any hope in. correcting 
the functions to which they may refer with sufficient celerity ; for 
active inflammation, once established in organs important to life, 
must be checked with promptitude, or the patient's life will be sub- 
jected to unnecessary danger, or be sacrificed. 

These and similar considerations, and especially in the actual 
state of medical science, oblige us to consider hy what other means, 
of a more prompt or general kind, we can stop vehement inflam- 
mation in particular parts or organs ; and this leads us at once to 
what I may call the common mode of treating inflammation : that 
is, by bleeding, and various other modes of evacuation ; by blis- 
tering, and other modes of counter-irritation ; and by certain other 
remedies which either equalize or reduce general action ; as tartar 
emetic, mercurj", &c. But I will again repeat, that, if the essential 
law and particular conditions of inflammation be an attempt, in its 
healthy manifestation more or less successful, to determine to the 
surface, it implies the necessity of partial circulation seen in the 
necessary congestion of the inflamed part ; it follows that what- 
ever our measures may be, whether one or one hundred, whether 
prescribed on scientific principles or merely at the suggestion of 
the wildest empiricism, — yet, if they do good, they should be either 
explicable on principles in harmonj' with such views, or they should 
be at least explicable on none which essentially controvert them. 
In other words, they ought to be demonstrably calculated to equalize 



395 



the circulation, or to determine inflammation to the surface, or both 
in conjunction, so far as regards the inflamed part. Now, if I mis- 
take not, a careful view of the measures about to be discussed will 
not only elicit a beautiful harmony in all the foregoing matters, but 
will even explain satisfactorily the actions of remedies, vv^hich, 
although perhaps of all the most potent, are those whose actions 
have been hitherto only guessed at, or not at all understood. 

RVACUATION OF THE BOWELS. 

In all cases whatever, supposing that not to have been previ- 
ously satisfactorily accomplished, I have already told you to begin 
by evacuating the bowels ; but I need not repeat more of what has 
been already observed on this subject. Acting on the bowels, with 
a view to make them accessories to the general plan of depletion, 
is another matter, which will be spoken of as we proceed : and 
now I will suppose the case urgent, and begin by discussing the 
abstraction of blood. 



BLEEDING. 

There is no remedy employed by physicians or surgeons which 
requires more judgment than the abstraction of blood ; nor any 
which has been employed with less discretion. The results of 
accidental injuries, and occasionally those of operations, shew that 
the resources of the animal oeconomy enable it to sustain the loss of 
moderate, and in some cases even considerable, quantities of blood 
with impunity ; or, if it produce mischievous consequences, that 
these are in many cases prospective ; so that, until lately, the con- 
nection between the loss of blood, and the effects w-hich have 
resulted from it, have been altogether unobserved. We bleed in 
various diseases with different intentions ; the only thing generally 
true, being that we bleed very often without any real necessity 
for this proceeding. But I am not alluding, at present, to any 
other class of cases than those in which active inflammation is 
present, and only to a certain class of these. Now I shall suppose 
that you have a case in which you had no opportunity of observing 
the commencement ; inflammation has occurred ; you only know 
the habits of the patient by report ; the thing clear to you is, that 



396 



the inflammation is established in some important part ; tlie sj m- 
ptoms inform jou that it is rapidly progressing. However desirous 
you may be of testing some remote cause as the real excitant of 
the inflammation, the present state of science does not allow you 
sufficient confidence to act on any suggestion of this kind which 
the case may offer, nor the pressing nature of the symptoms suffi- 
cient time. In short, it appears to you that the patient's safety is 
inconsistent with the further progress of mflammation ; that this 
must be arrested ; and, on consideration of all points, you de- 
termine that bleeding is necessary. Be clear then, in such a case, 
as to your object, and you will not fail to fulfil it with suflicient 
promptitude and energy. This object is to diminish the action of 
the heart and arteries generally, and, through this, that of the 
vessels in the part inflamed. In doing this, you are to regard the 
effect you are desirous of producing, and not to be thinking of the 
number of ounces which any preconceived notion may induce you 
to consider as safe or necessary. 

It is, however, quite consistent w^ith this singleness of object to 
remember that the blood is an important fluid ; and that, whilst 
you are only to be satisfied by reduction of action, yet you must 
effect this in such a manner as not to render the abstraction of 
blood larger than necessary. 

In accomplishing this, we find that two circumstances are es- 
pecially convenient ; first, the quick abstraction of the blood, by 
which the s} stem is much sooner affected than when draw^n slowly ; 
and, secondly, a position which also favors the early production of 
fainting, or a state approaching thereto. We bleed, therefore, from 
a large orifice, having previously raised the patient's head to the 
upright position. Having opened a vein, you allow the blood to 
flow rapidly until your patient is about to faint, or very nearly ap- 
proaches that condition. This state will be characterized by the 
pulse becoming soft and compressible, and by its beating more 
feebly ; the patient gets pale ; perhaps heaves a sigh ; the eyes will 
lose their lustre ; and a dewy perspiration will break out on the 
face and forehead. Tins is the state you desire. Sometimes a 
patient will very suddenly faint ; but, if immediately laid in the 
horizontal position, he soon recovers. Others will again tell you, 
w^hen the symptoms which I have mentioned supervene, that " they 
are going ;" but, if you draw the blood quickly, and the case be 
proper for bleeding at all, you need never be under any apprehen- 
sion. But, if you draw the blood slowly, or whilst a patient is 



397 



lying down, bleeding him until lie faints, or until he approached 
that state even in the manner which I have described, might very 
probably prove fatal to him. In different cases, you are told to 
bleed according to the constitution of the patient ; that is, if he be 
weak, you are to bleed to so many ounces ; in other cases, to so 
many more ; and, in the plethoric and strong, in the manner which 
has been described. 

Now I should be sorry to risk, or even to appear to be guilty of, 
hasty generalization ; but still 1 must tell you the result of my ex- 
perience : and although, therefore, I am far from sajing that, in 
some cases, the abstraction of giveii quantities of blood may not 
be judiciously prescribed, yet, in a case of actke inflammation, 
such as I have supposed at the commencement of this chapter, I 
do not believe that there is one case in a thousand in which 
you may not bleed most effectually, most safely, and with most 
oeconomy too, in the manner directed. My conviction is, that all 
that has been said about ounces, applies to cases of altogether a 
different kind, or cases in which, if they be infiammation, no bleed- 
ing at all is necessary ; and that a merit has been ascribed to 
bleeding which it does not deserve. In active inflammation such 
bleedings appear altogether bad practice ; unless, indeed, as not 
unfrequently happens, from a large orifice, they produce reduction 
of power. From a small orifice, or by repeated bleedings, patients 
will sometimes bear, without any material reduction of action, a 
loss of blood which, taken at once, would produce fainting in the 
strongest man that ever lived ; so that, to suppose that the abstrac- 
tion of a smaller quantity than that necessary to produce the im- 
pression I have described, is a real oeconomy of the blood, is a 
serious error. Besides this, the abstraction of small quantities of 
blood, or I should rather say definite quantities, without reference 
to the effects which we wish to produce, is often mischievous, in 
consequence of the excitement and reaction which it produces, — a 
fact with which very few, who have had much experience, can fail 
to be familiar. 

I cannot safely adduce any appearance of the blood as guiding 
you in conducting this remedy. The usual appearances supposed 
to characterize the blood in inflammation, are its surface presenting 
more or less of a hollow when coagulated (technically, cupped), 
and a stratum of dirty -yellowish lymph on its surface (buffed or 
buffy coat), either separately or in conjunction : but whilst neither 
of these appearances are constant in inflammation, they occur 



398 



wliere inflammation is not present. Thej are presented also in 
cases where large quantities of blood have been drawn, when they 
had not accompanied the first bleeding. They can, in fact, be re- 
garded neither as evidence of the presence of inflammation, nor as 
demonstrations of the propriety of blood-letting. 

When you bleed then in inflammation, you do it to subdue 
vascular actions generally ; and, through this, those of the part 
affected in particular. It is highly probable that other efl"ects, even 
more directly bearing on the disease, are produced by such bleed- 
ing ; for it is very common to perceive determination to the surface 
follow immediately on its employment. Thus, perspiration and se- 
cretion from various organs very commonly follow on the abstrac- 
tion of blood in severe cases of inflammation ; thus it is well known 
that the abstraction of blood is frequently followed by effects which 
we endeavour to produce by other remedies. 

The peculiar effects of mercury are known to be produced 
more quickly in many cases where bleeding is superadded ; and in 
cases not of an inflammatory nature, and in those which are ac- 
compauied by inflammation at the surface, the abstraction of blood 
often hastens the disappearance of the local disturbances. But the 
objection in such cases to bleeding, is that it is unnecessary, and 
strikes not at the real causes of the disorder. 

x\t one time I used to bleed in order to assist in the correction 
of intractable cases of disordered secretions, and in cases of various 
affections of the surface, not usually included in our ideas of inflam- 
mation : but experience has convinced me that the bleeding is not 
only unnecessary, but that it is not even more quick in regard to 
the local manifestations in such cases than other more scientific 
modes of proceeding. I mean that superaddition to attention to 
the general health which directs it to the organ especially in fault, 
and which enforces it through the agency of the sympathies. 

Notwithstanding, therefore, that bleeding may not produce its 
controlling effect in inflammation wholly by subduction of action, 
yet this is the only sure indication on which we can rely for benefit 
from that remedy ; for, in regard to any other effects, it is not 
only uncertain, but seems generally inferior to many other modes of 
proceeding. I have already observed largely on this remedy ; and 
this I need not repeat. 

As there are two kinds of blood in the body, reflection might 
naturally suggest that some difference might occur, accordingly as 
the blood abstracted was venous or arterial. I am not aware that 



399 



we have any thing very satisfactory on this subject. We cannot 
perceive that the abstraction of arterial blood possesses any ad- 
vantage ; whilst, as the object is always to reduce action rather 
than power, the venous blood may be reasonably regarded as more 
perfectly fulfilling this indication ; since, as regards action, it 
is equally efficient ; whilst, in reference to power, venous blood may 
be regarded as less a loss, cceteris paribus, than arterial, in that it is 
not fitted for the purposes of circulation until it has undergone 
a change, which shews that it contains considerable quantities of ex- 
crementitious matter. \Yith regard to the manner in which bleed- 
ing should be conducted, I consider it is by no means unworthy of 
more precise directions than are generally given ; for the result of 
neglect in this particular, is, that very few people bleed properly, 
still fewer w^ell : but I regard tliis as more properly connected 
with the consideration of " consequences arising from vensesection," 
of which I may speak hereafter. 

Regarding then what is stated in this section, with what has 
been before observed on the subject of bleeding in inflammation, 
you will perceive that, with the implied exception, I consider bleed- 
ing as any thing but the best remedy in inflammation ; that, for 
the reasons assigned in a previous chapter, it does not minister 
necessarily to the causes of inflammation ; since it often fails in 
subduing it ; and inflammation is often subdued without it ; and 
that, when successful, it is hardly ever trusted to singly. 

That the causes of inflammation cannot be referred to the 
quantity of blood, but to its unequal distribution ; and that bleed- 
ing has no direct tendency to alter this state but by subduing 
actions of all parts, and thus making the whole suffer for the part. 
That its necessity, even in the present state of our knowledge, is 
only indicated in cases where this necessity results, — first, rather 
from the advanced period at which we see the case, than from its 
intrinsic nature : or, 

Secondly, from the fact that, the real causes of the inflamma- 
tion being undiscoverable, we are called on to stop it at all hazards, 
and by any means. 

That such causes may in general be discovered, and that they 
have hitherto escaped detection from the absence of sufficiently 
enlarged and correct view^s of inflammation, and from the real 
principle on which bleeding acts not having been sufficiently con- 
sidered, or altogether overlooked. 



4U0 



That the loss of a considerable quantity of blood may, in many 
cases, as is proved in accidents, be borne with apparent impnnity 
as regards its more immediate consequences ; and that there is 
reason to believe that this impunity may have been really the ex- 
planation of many cases wherein men have attributed advantage 
to blood-letting. 

Notwithstanding the foregoing, as regards the more immediate 
effects of loss of blood, that its prospective effects are often demon- 
strably injurious. 

That these effects are various and puzzling conditions of the 
circulation, chiefly characterized by determinations to particular 
parts ; great disorder of the nervous system, simulating those 
which take place from plethoric conditions of the body, — pheno- 
mena which will hereafter be more particularly considered in rela- 
tion to the cases in which they occur. 

That Nature bleeds only imder coercion ; and that, therefore, 
bleeding is not a remedy which can be strictly regarded as one of 
those which can be included under the head of healthy preservative 
function. 

That a more true view of natural bleeding, is that w^hich re- 
gards it as disease, — that is, as a substitute for more healthy pre- 
servative action from which Nature is prevented, or to which the 
powers of the oeconomy are unequal,— just as inflammation is a 
substitute for those preservative actions, w^hich, in more healthy 
states of the oeconomy, are undertaken by secreting, or more com- 
monly excreting, organs. 

That bleeding in inflammation, therefore, should be even 
already restricted to cases — 

First, where we cannot discover the real cause of the inflam- 
mation ; 

Secondly, where the inflammation is already so advanced that 
the threatened destruction of life, or a particular organ, renders any 
further progress of it unsafe ; 

Thirdly, in cases which, though less severe or urgent, other 
measures prove ineffectual in the equalization of the circulation 
(very rare) ; 

Fourthly, in such states of decided plethora, — that this con- 
dition itself ma}-, independently of disturbance of particular organs, 
be regarded as the predisposing cause of the inflammation (in my 
experience, rare also) ; 



401 



Lastly, in cases where the patient, either demonstrably, or with 
a reasonable probability, cannot be depended on for the observance 
of treatment prescribed (cases not very uncommon). 

In concluding this section, I would apprise you that it is im- 
possible to include all I would say in relation to this important 
subject : it requires many cases, and of apparently very differ- 
ent kinds, for its full illustration : and, further, that I expect 
much difference of opinion on this subject ; for nothing astounds 
some men more than the announcement, that bleeding is not the 
best remedy for inflammation. I can only say that I have bestowed 
much reflection on this subject ; that I have no preconceived no- 
tions in regard to it ; that I have bled as largely as any body ; and 
that I continue still to do so in certain cases ; but that where I 
now bleed one patient, I used to bleed perhaps twenty ; and that 
the difference in practice has not only satisfied me with the su- 
periority of the more measured employment of this remedy, but 
that it has led me to a more enlarged and true perception of the 
real nature of various aifections, than I could have attained had 
my investigations been obscured by the employment of bleeding 
in its ordinary frequency. On this, however, as on all other ques- 
tions, I only w-ish that the subject should be fairly and patiently 
considered : my object is truth, not the support of any particular 
opinion. I must also observe — 

That organic diseases of the heart, or lungs especially, will 
materially modify any observations that can be made in connec- 
tion with the general consideration of blood-letting ; but as these 
will have reference to various circumstances affecting both the kind 
and nature of the disease, and the various concomitant conditions 
of the oeconomy, they can only be considered properly in connec- 
tion with such diseases. 

I have already observed that bleeding is frequently followed by 
determination to the surface, by means of the skin or some other 
secretion ; and I may add, that when it does good, it is almost in- 
variably followed by some such manifestation. But, although this 
is in harmony with the real nature of inflammation, as is that 
equalization of the circulation effected through a general reduction 
of all vascular actions in common ; yet it is, in the generality of 
cases, a method much less uniformly certain than some others • 
whilst, as regards the powers of the oeconomy, it is by much the 
most expensive of all. I. say nothing with regard to the repetition 
of blood-letting, since this will be determined by the same consi- 

D D 



402 



derations which led to its primary employment. In estimating the 
truth of the foregoing remarks, I must guard you from drawing 
conclusions from cases wherein bleeding has been emploj ed simul- 
taneously with other remedies ; especially if, as generally happens, 
these be such as experience demonstrates to have great power in 
the control or removal of inflammation. 

LOCAL BLEEDING. 

I have already adverted to the principle on which local bleed- 
ing appears to act in contributing to the reduction of inflammation. 
I have endeavoured to shew, that, in the ordinary employment of 
it, this principle is different from that of general blood-letting ; but 
that, like it, it ministers to the efl'ect, rather than the cause of the 
malady. Local bleeding, I mean in regard to active inflammation, 
has been usually employed — 1st, where general bleeding has been 
carried so far as the powers of the patient appear to justify, with- 
out the subd action of the inflammation : 2ndly, where, though the 
powers of the patient have not been subjected to any previous 
general abstraction of blood, they are regarded as already unfitted 
for its employment ; this being especially the case where organs 
are previously diseased : 3rdly, in cases where the inflammation 
is seen at a very early stage, where we have reason to believe it to 
be very slight, or even its existence doubtful : and, lastly, in in- 
flammation on the surface of the body ; which last will be more 
particularly spoken of when the diseases to which they refer are 
treated of under the names by which they are conventionally 
designated. 

The modes adopted for local bleeding, are the application of 
leeches or cupping ; for opening the jugular vein or temporal ar- 
tery, though instituted with certain views to the locality of the 
inflammation, does not range itself properly imder the head of 
local bleeding. So indeed in regard to leeches and cupping ; it is 
quite possible to institute either of these measures in a manner 
which refers their operation to the general, and not to the local, 
abstraction of blood. But I speak of them as commonly employed. 

In general, I think cupping is to be preferred to leeches as a mode 
of local depletion. We know the quantity we take ; v/hich, as we 
here bleed on a different principle, is important ; secondly, we obtain 
the blood more quickly, and independently of the vessels actually 
opened, we powerfully determine the blood to the surface over 



403 



which the cupping-glasses are applied. This is a great advantage, 
and is seen in dry cupping, that is, where the glasses are applied 
without the infliction of any wound, — a mode of proceeding bj no 
means so extensively employed on the human body as it ought to 
be, although its general utility is, I believe, not to be questioned. 
The truth is, that it determines to the surface without reduction of 
power, — a very desirable combination. To obtain benefit, how- 
ever, the glasses should be applied for a considerable time ; but 
I shall have occasion to enlarge on this subject hereafter. x\nother 
advantage of cupping over leeches, is, the avoidance of that ex- 
posure to cold which is almost unavoidable in regard to the ap- 
plication of leeches ; and which, in many cases, it is especially 
desirable to avoid. Leeches are often, too, very fatiguing to the 
patient. 

Where local bleeding is judged necessary, leeches, however, are 
occasionally convenient, and especially applicable to external in- 
flammation when the skin is tense and tender, and when the 
cupping-glasses could not be either conveniently applied, or not 
without the creation of additional excitement, as in severe cases 
of erysipelas, for example. 

The action of local bleeding is clearly, in many cases, the same 
as general bleeding ; but this has been spoken of ; and in certain 
cases, such as inflammation of large surfaces, attended by already 
reduced powers, the endeavour to produce general effect by local 
bleeding may combine the advantages of both modes of proceed- 
ing : in this case we apply four or five dozen leeches at once. 

If you apply leeches in children, that is, of three or four years 
old (and if younger, the caution is the more necessary), you should 
be aware that it is by no means safe to allow them to bleed inde- 
finitely ; for even two or three leeches, or even one, in infants, 
may possibly be followed by so large a loss of blood as to prove 
fatal. I make no apology for impressing tliis, because, to my sur- 
prise, I have found that some of the profession are not sufliciently 
aware of this fact. 

I was once called to the child of a physician, who was already 
pale and exsanguious from the application of three leeches, and who 
would have died, I am convinced, had the bleeding not been 
promptly arrested. Another medical man, otherwise exceedingly 
well informed, told me, as an extraordinary fact, that he had nearly 
lost a child from the application of a few leeches. 

Many years ago, a patient whom I attended myself, in con- 

DD 2 



404 



sultation, was very nearly dying from the application of three 
leeches. The necessary caution had been given, and the bleeding 
stopped. The child, however, being restless, had, in moving about, 
rubbed off the lint ; and the mother, alarmed at the dying appear- 
ance of the child, removed the bed-clothes, and found that there 
had been a vast loss of blood. The child rallied, however, from 
this ; but it is worthy of remark that she ultimately died of the 
inflammation. 

Leech-bites in very young children, therefore, should only be 
allowed to bleed for half an hour or an hour, according to the num- 
ber which have been applied, and the circumstances of the case. 
They are easily stopped by a double fold of lint, and a little flour 
placed by the finger on the part, and held there till it adheres. The 
foregoing case will also suggest the expediency (the child being 
in bed) of securing the lint for a time on the part by a slip of 
plaster, or some similar expedient. 

Local bleeding, then, where it is not employed as general bleed- 
ing, opposes congestion of the part, the necessary element of in- 
flammation, and thus affords more time for the effect of other and 
more important remedies w^hich may be in simultaneous operation, 
in cases w^here bleeding is at all necessary. Again, it determines 
to the surface, and that nearest to the inflamed part ; between 
w^hich and such part there is, as formerly shewn, great sympathy. 
Cupping evidently produces such determination in a very marked 
manner ; whilst the openings on the surface, made in common by cup- 
ping and leeches, may increase this determination on the hydraulic 
considerations already mentioned'^. 

PURGING. 

The too prevalent idea, that the most powerful agent in inflam- 
mation is depletion, has naturally led men to effect this, in various 
cases, by that indirect method afforded by the excitement of 
various secretions ; and the large surface of the alimentary canal 
has been frequently rendered contributory to this purpose. 

I have already spoken of the absolute necessity of emptying 
this canal of its contents, and the reasons on which we ground 
this necessity. 



* See page 310. 



405 



Certain advantages are often obtained by following up such 
evacuations of contained matters by the subsequent promotion of 
increased secretion from the mucous surface ; and the best mode 
of effecting this is by giving small doses of saline purgatives, to 
M^hich minute portions, as one eighth of a grain, of tartrate of anti- 
mony may be added with benefit. The advantage derived from 
this source depends on different circumstances in different cases. 
Sometimes alimentary disturbance is the real cause on which the 
inflammation depends ; and, in such cases, the excitement of secre- 
tion (especially if pain or other indications of undue excitement be 
avoided) tends to relieve disturbance in a natural manner ; that is, 
by secretion. Besides, purging is not only in itself a determination 
to the surface, but, by the sympathy of the bowels with the skin, 
it often produces determination to the latter organ — a thing, in a 
general sense, much more important. 

In other cases, again, aperient medicines appear to produce 
benefit by creating powerful determinations to a surface distinct 
from that which is inflamed ; and thus oppose congestion (the 
necessary element of inflammation), quoad the inflamed part. In 
this case, they appear to produce benefit on the same principle as 
that on which counter-irritants do (as blisters, &c.) when applied 
to the skin. 

In certain cases, also, where the inflammation is not very ur- 
gent, and where the disorder of the system seems to depend on a 
general plethora, rather than on any disorder of a particular organ, 
purges reduce the circulating fluids by means of the secretions, 
which is found not to disturb or reduce the general poiver of the 
oeconomy prospectively, so much as direct depletion. 

Purges, therefore, evidently address themselves to the real 
causes of inflammation ; first, in determining to the surface abso- 
lutely ; secondly, in determining the blood from the inflamed part, 
and thus, in regard to it, equalizing the circulation ; and, thirdly, in 
cases suggesting its expediency, they are indirect modes of depletion. 

In affections of the bowels themselves, the excitement of their 
secretions would be of all things perhaps desirable, could we ac- 
complish it. But here purgatives are of very equivocal advantage. 
I speak thus cautiously, because my experience on this part of 
the subject is chiefly drawn from inflammation, as it occurs in con- 
nection with strangulated hernia, in which I feel certain that pur- 
gatives are seldom attended with benefit ; whilst I am equally con- 
vinced that they have often been highly injurious ; and, in some 



406 



instances, I am satisfied tliat the excitement and disturbance 
which thej create has been the cause of the inflammation in such 
cases, as I hope hereafter to be able to shew. 

Notwithstanding, therefore, that purging is advantageous, and 
in the different modes which I have mentioned, and probably in 
some cases in all of these modes, — still we cannot say that prac- 
tice justifies our placing the same reliance on it in severe and urgent 
cases as we can on other remedies, — I mean regarded as remedies 
of general application in such cases ; and, as to the excitement of 
secretion fi-om the bowels, we find that, in many cases, we are 
obliged to keep this witliin very confined limits ; as much action 
here vitiates the power of one of our really most potential measures. 
These I will now consider; repeating only that I speak of purgatives 
in their general applicationy and not with relation to those cases in 
which certain disturbances of these viscera are, through the agency 
of their sympathetic influence, the cause of the inflammatory de- 
termination to the inflamed part. 

We find that general reduction of action and power wdll by no 
means ahvays subdue inflammation ; and this remark applies to 
bleeding with at least the same force and truth as it does to any 
other mode of effecting such reduction. We learn this by the 
direct experience, that the most severe abstraction of blood will by 
no means, in every case, effect the object we desire ; and that, 
although practitioners in general place greater reliance on bleeding 
than on any other measure singly considered, — yet they scarcely 
ever trust its single influence. 

Further, we find that the existence of inflammation of the most 
dangerous kind is by no means inconsistent with exceedingly re- 
duced power ; since we observe this combination in cases where no 
means have been instituted for reducing the powers or actions of 
the system ; but, so far from such cases being favourably influenced 
by such a combination, they are, under the present modes of treat- 
ment, of all others the most dangerous and unmanageable. These 
cases oblige us to attem.pt the relief of inflammation by other 
means, which may reduce the actions of the system without dimi- 
nishing its powder ; and, whilst they involve problems alike difiicult 
to physicians and surgeons, impel us to endeavour at improved 
modes of practice, in the doubt, which they naturally suggest, 
whether a practice which evidently consists for the most part of 
ministering to symptoms or effects can be the scientific, true, or 
natural mode of treating these dangerous disorders of the animal 



407 



oeconomj. Besides, if those inflammations be really the most 
dangerous or intractable, which are characterized by simultaneous 
prostration of power— and it is notorious that they are so — the idea 
naturally occurs, that, where bleeding does not effect its object, it 
may be exceedingly injurious. 

There is no mode of meeting these difficulties but by a more 
enlarged enquiry into the real causes of the malady ; and by test- 
ing the influence of these causes by acting on our supposed dis- 
covery, in cases where such discovery seems the result of a 
reasonable induction, from the facts previously ascertaiDed, and 
the relations which they bear to any known laws of the animal 
oeconomy. The manner in which this should be done 1 have en- 
deavoured to explain, both generally, in the investigation (see Dis- 
course II), and also in cases of inflammation in particular. 

I say, then, that other remedies than bleeding, even when this 
has been liberally employed, are found necessary ; and endeavours 
are made to reduce the inflammatory actions by other and less ex- 
pensive measures as regards the expenditure of vital power. The 
means employed with this view are various ; but one of the most 
potent and most frequently employed is the tartrate of antimony. 
The phenomena observed during the administration of this remedy 
are not in every case the same. Generally, we observe the sto- 
mach afl*ected by nausea ; sometimes sickness ; and secretion takes 
place either from the skin, bow-els, or kidney ; and sometimes from 
all of these organs, but the skin especially. We observe also that 
there is considerable diminution of force in the action of the 
heart and arteries, the pulse usually also becoming softer. We 
thus obtain a diminution of vascular action and an increase of 
secretion, and especially in an organ (the skin) which determines 
to the surface, or of which the ordinary functions are emphatically 
the separation of excrementitious matters. 

In different cases, different organs are effected ; and even where 
all these which I have mentioned are excited, one of them is com- 
monly more active than the others, and this will vary in different 
persons. In a case already mentioned, a small dose of tartrate of 
antimony appeared to have aff'ected the skin in some degree, the 
bowels very profusely, and the kidney not at all. These differences 
occur, in some degree, in endless shades of diversity ; but the skin 
is almost always more or less affected, except when the remedy 
proves entirely inert, which happens but seldom. 

In particular cases, good effects may result from the remedy 



408 



acting on particular organs, in conformity with wliat I have ob- 
served as to the causes of inflammation ; but, for the most part, 
the parts which we are most desirous of influencing are the sto- 
mach, skin, and the heart and arteries. Practically, we find that 
the best mode of accomplishing these objects is to prescribe the 
remedy in such doses as shall produce and maintain a state of 
nausea of the stomach ; and the phenomena of sympathy shew^ us 
that this condition, be it obtained how it may, always produces 
perspiration, with a depression of the action of the heart and arte- 
ries. We therefore give one half, one fourth, or even one sixth or 
one eighth of a grain, every two or three hours ; at least these are 
the doses most commonly employed in this country. When we 
give larger doses than these, it is usually in combination with 
calomel or opium, or both — remedies of which I shall speak pre- 
sently. On the continent, however, much larger doses than these 
are commonly administered. I do not know that any advantage is 
derived from such doses (which vary from several grains, even in 
some cases, I believe, to a scruple or more at a dose), so long as 
vomiting is to be avoided ; and, although vomiting in particular 
cases is useful, yet this is not the general intention, nor the most 
desirable thing : continued nausea, and the sympathetic affection 
consequent on it in the maintained determination to the surface, 
and reduction of the heart's action, is the thing we seek ; and, m 
this view, the smaller doses given, at shorter or longer intervals, 
are alone necessary ; indeed they appear to answer the intention 
most successfully. 

I do not regard the plan of combining this remedy with calomel 
and opium as good practice ; I do not say that it may not answer 
in particular cases ; but generally opium does not, I think, assist 
the tartrate of antimony ; whilst the latter has rather a tendency to 
interfere with the effects of opium. It is better to give the tartrate 
of antimony first, and then proceed to the calomel and opium, 
should the case require it ; or, if it be very urgent, to begin with 
the calomel and opium, omitting the tartrate of antimony. I do 
not wish you, however, to understand me as putting much stress on 
this difference of plan ; I only tell you my own practice. The tar- 
trate of antimony is a very powerful and efficient remedy ; and it 
is only in severe or neglected cases, or cases in which some particu- 
lar organ is affected, that calomel and opium become necessary ; 
but, in all urgent cases, where we have little time, it is of the first 
consequence not to delay this remedy. 



40d 



The effects which I have described as resulting from tartrate of 
antimony may be occasionally obtained from other remedies. 
Thus, small doses of ipecacuanha, jalap, or any substances which 
produce nausea, will, with greater or less degree, lower the action 
of the heart and arteries, and determine to the skin or some other 
organ ; and these may be given in combination with opium, hen- 
bane, digitalis, camphor, and many other things. Tobacco has 
also a remarkable power in lowering the action of the heart, and 
producing nausea and perspiration ; but this, and remedies of a 
like nature, are too dangerous to be commonly admissible, and 
uncertain in their mode of action : therefore, although it is useful 
to know of them, and especially, more than all, to understand 
the common principle on which they seem to act, to meet cases of 
emergency, or when other means may not be at hand, still the 
tartrate of antimony is the remedy to be preferred in obtaining 
the objects which I have mentioned. 

You see, then, that the action of the remedy is to excite nau- 
sea, to determine to the surface, and to do what always follows 
these circumstances — lower the action of the heart and arteries. 
This is combining all the elements of good treatment. The deter- 
mination to the surface tends to disturb the condition essential to 
inflammation ; viz. congestion elsewhere ; and this in a manner 
exactly in conformity with Nature's own processes, as has, I trust, 
been sufficiently shewn ; whilst the reduction of arterial action is 
also accomplished. 

The conditions of serious inflammation — viz. general increase of 
action, with particular increase and congestion in a part — be- 
come thus reversed, in that the general action becomes diminished, 
with particular determination to the whole surface of the body. 
This, whether evinced by secretion or irritation, is a great gain ; 
generally, in a practical sense, curative in both cases. 

As I shall revert, in the sequel, to the tartrate of antimony, in 
common with other measures, I need say no more on its practical 
administration. 



OF MEASURES APPLIED TO THE SURFACE OF THE BODY, — 
BLISTERS, ISSUES, SETONS, VAPOUR AND WARM BATH, ETC. 

You have already seen that the various measures of which I have 
spoken involve, practically, attempts at equalizing the circulation ; 



410 



and this chiefly by cletermiiiing the blood from parts labouring 
under inflammation, and chiefly to the surface of the body. Now, 
amongst the ordinary remedies ibr inflammation, and those which, 
in many cases, exert great power in its subduction, we include the 
application of blisters and issues, setons, certain substances which 
produce irritation in another way, as the ointment of tartrate of 
antimony, and those which merely excite the part to which they are 
applied by making it red, determining the blood there, in fact, and 
which have been simply termed rubefacients. Of these last, any sti- 
mulating substance is an example ; mustard, applied in various forms, 
being the most powerful. All these remedies are included in the 
term " counter-irritants:" they were also said to act by revulsion 
and derivation ; the latter, though an old term, expressing their real 
mode of action perhaps most perfectly. Now they all appear to act 
on the same principle ; the obvious phenomena to which they give 
rise being, first, a determiuation of blood to the part to which they 
are applied (the surface of the body), and the superinduction of 
inflammation, effusion either of serum or pus, according to the 
remedy or the duration of its application. K blister produces 
determination of blood to the surface ; then inflammation ; then 
little blisters, whence its name; and, lastly, secretion of matter, 
which we either continue to excite by sustaining the irritation, or 
not, according to circumstances. The ointment of tartrate of an- 
timony produces suppuration, in the form of little pustules, which, 
discharging their contents, either heal, like all other little abscesses 
(which pustules are), or go on to ulceration, accordingly as we with- 
draw or continue the cause of their production. 

You see how exactly this is in harmony with what I have 
already observed in regard to ulceration. Setons and issues pro- 
duce suppuration by a continuance of the original causes of the 
inflammation ; and, when these are removed, they both heal. 

We makeanissue generally by destroying a piece of skin, by means 
of caustic. This (generally the caustic potash) is pounded in a mor- 
tar and mixed with soap ; a piece of double plaster, with a hole 
cut in it, somewhat less than the size we intend the issue to be, is 
laid on the part ; over this hole we spread the paste so prepared ; 
and then we press the sides of the hole close to the skin by a cyhn- 
der of linen or anything at hand, securing it by straps of plaster : 
we allow it to stay on for about five hours. vA'hen we find a piece 
of skin destroyed, we poultice the part ; the deadened skin is 
thrown off; and, if we wish the issue to be maintained, we put a 



41J 



string of glass beads in its circumference, to prevent its healing ; 
and then either dress it with simple spermaceti ointment, or some 
of a more irritating kind, as we feel satisfied with the irritation 
produced, or as we wish to increase it : the latter is seldom neces- 
sary. When we wish the part to heal, we simply remove the im- 
pediment (that is, the beads), when the wound becomes repaired in 
the usual manner. 

A seton is made by simply gathering up a portion of skin, and 
conveying through it either a skein of white silk or a piece of 
tape, by means of a lancet-shape knife with an eye, through which 
the silk or tape is previously introduced (technically called a seton- 
needle) ; and, having thus introduced it, we allow it to remain, 
contenting ourselves with the irritation and suppuration which, as 
a foreign body, it produces, or increasing them by convening irri- 
tating applications to the part. When we wish all these processes 
to cease, we simply remove the cause ; that is, the tape or silk, as 
the case may be. Sometimes Nature, if not counteracted, will 
throw olf both the seton by removing the skin covering it, and the 
issue by pushing out the beads, by means of the formation of gra- 
nulations beneath them ; all w^hich is highly interesting, and often 
affording hints of great value, as you will see when particular dis- 
eases are considered. 

In active inflammations, however, it becomes very important 
that we should produce this determination to the surface, which all 
these means effect in common, by those which will do it in the 
shortest possible time. Hence it is that blisters are, of all other 
means, most effectual ; whilst they allow us to maintain the irrita- 
tion just as easily as any of the others. Mustard, boiling water, con- 
centrated mineral acids, and a number of other things, will accom- 
plish this object ; but the best and safest mode in practice is to 
apply the Spanish fly, previously comminuted, and mixed in the 
form of an ointment or plaster. This is usually applied on the 
surface, opposite the part in which we believe the inflammation to 
be seated ; as on the chest, in various affections of the lungs ; on 
various parts of the abdomen, in the affections of the different 
viscera contained in it ; in inflammation of joints, either on or near 
the skin covering them ; and so on. 

There are some remarks and cautions, in respect to blisters, 
which must be mentioned. In the first place, w^e find that, in 
many eases, they seem to produce most good when we have 
previously checked, at least in some degree, the inflammatory 



412 



action : and, in regard to joints, Mr. Abernetliy used to Ibrbid 
their employment until this had been, in some measure, fulfilled. 
More particular directions, in this part of the treatment of joints, 
belong to the local treatment of such affections ; but I may observe 
here, that the main consideration refers to the contiguity of the _ 
blister to the part inflamed. 

There seems good reason for caution in this respect. If a 
blister be applied over a part in an active state of inflammation, it a 
certainly does, in some cases, communicate excitement to the part 
inflamed ; but never, that I know of, when applied in the vicinity. 
That this is the true explanation, appears probable, from such 
effects being most common in respect to joints, between which and 
the skin scarcely anything but cellular tissue intervenes ; and affec- 
tions of the eye, most of which, as I have observed, occur on a 
surface continuous with the skin. Indeed, in the eye, we for the 
most part act on such a view of the matter, and apply our counter- 
irritants behind the ears, in preference to any situation more conti- 
guous to the organ. In fact, this excitement of inflamed parts by 
blisters applied to the skin over them is not very common, how- 
ever, in the chest, where it does occasionally happen ; whilst, in in- 
flammations of the abdomen, so far as my experience goes, such 
excitement never happens as a consequence of their application. 

Blisters occasionally produce irritation in the urinary organs ; 
but this seems to result from the actual absorption of the irritating 
principle of the Spanish fly ; for we do not find it following blisters 
otherwise produced : and, in respect to the fly, we prevent it pretty- 
certainly by the interposition of a piece of silver paper, as it is 
called, between the blister and the part to which it is applied, 
though perhaps not invariably. 

In children, blisters should be applied with caution ; that is, 
they should be either very small, or only allowed to remain suffi- 
ciently long to produce vivid redness of the surface, which, though 
the blister be removed, is usually followed by the characteristic 
consequence of the application. If we allow them to remain on as 
long as in the adult, the inflammation excited is so violent, that, 
taking place in states of reduced power, of which the disease for 
which they are applied is either the evidence or the cause, sloughing 
is apt to supervene. 

We have had, at different times, numerous examples of this in 
the Dispensary, whither children are brought, who have been re- 
covered from the ailment for which the blister was applied, for the 



413 



relief of the sloughing ; and such eases are always serious, and oc- 
casionally fatal. 

The treatment consists, of course, in attention to the general 
functions of the body, soothing applications to the blister, a bread 
poultice, and such measures as are calculated to give strength to 
the system, consistently with the avoidance of excitement. Ex- 
ceptions to the selection of blisters as counter-irritants or deriva- 
tives to the surface also are occasionally indicated in those indivi- 
duals in whom this active excitement of the skin produces unusual 
irritation ; the whole system becoming exceedingly excited and 
otherwise disturbed : but, in acute inflammation, this rarely hap- 
pens : when it does, some other form of counter-irritation must be 
substituted, as the application of a mustard poultice for a short pe- 
riod, or some other mode of irritation. You see, however, that 
these remedies have alike one object — the determination of blood 
to the surface ; since, whether we restrict our plans to this, or ex- 
tend it to the production of inflammation, they are both extensions 
of the same process ; and that they are powerful remedies in in- 
flammation is no less deducible from the consideration of the na- 
ture of that process, and the law under which it occurs, than that 
they are demonstrably sach as a matter of experience. But, if 
these considerations point so strongly to determination to the sur- 
face of the body, as being the chief object in all inflammations, so 
we are naturally led to see whether we cannot extend the influ- 
ences, thus successful when applied to parts of the skin, to larger 
districts ; in fact, to the whole surface of the organ. In contem- 
plating this, however, by means of blisters, or any other mode of 
counter-irritation, we immediately And that inflammation of a large 
portion of skin is a thing just as dangerous as the inflammation of 
any other part, as severe burns emphatically demonstrate; so 
that w^e are led to think of milder measures. Of these, warm or 
vapour baths are examples ; and, accordingly, we find that warm 
baths are occasionally of great benefit ; but, hi no respect, so pow- 
erful as are those of vapour. 

Baths may consist either of hot air or steam, and they may be 
either medicated or otherwise. I have no experience of medicated 
vapour baths in those active forms of inflammation to which I am 
now referring ; but of the efficacy of steam baths I have had a 
large experience in different cases. 

As they are too expensive for public practice, I contrived a very 
simple apparatus for their administration, which I find perfectly 



414 



efficient; and I gave tlie sketch to Mr. Livermore, of Oxford- 
street, who makes the whole affair, I find, for nine shillings. It 
consists of a conveniently contrived kettle and a couple of pipes ; 
and it answers exceedingly well. 

It was this apparatus which I used in the case of influenza 
which I mentioned (page 198); and I will just briefly relate 
another example of its successful application ; I attended an 
elderly gentleman with acute inflammation of the bladder, re- 
quiring the anti-inflammatory treatment in all its activity; and 
even then I had great difficulty in saving him. As his skin was 
very sensitive, and as he was somewhat incautious, I did not press 
the steam bath ; besides, he rather objected to it, and I had then no 
experience of its effects in such a case. A few months after this, I 
had a similar case in the Dispensary, in a man whose employment 
obliged him, as soon as he could move at all, to be out at night as 
a watchman. He got some benefit from the usual treatment, with 
calomel and opium, which had also been used in the former case ; 
but still I could not altogether relieve him under circumstances so 
unpropitious ; and he continued to suffer a great deal of irritation, 
and to void large quantities of ropy, puriform mucus from his 
bladder : I now advised the vapour bath, and the third night it 
produced most profuse perspiration; the secretion of the mucus 
entirely ceasing in one night. This recurred in a slighter degree, 
and ceased again on alternation with the use of the bath, until at 
length it ceased altogether. I have not seen the man for some 
months, except once accidentally in the street ; but I believe that 
he remains well. As he has another complaint, he will probably 
not remain so long, since he has not continued his attendance so 
that it might be completely removed ; but as this malady did not 
trouble him, I suppose he w^ill wait until it does, as his employment 
renders attendance at the Dispensary very inconvenient, and the 
necessary restrictions, unless they become imperative, nearly 
impracticable. 

I may observe that an extension of this application of warmth 
and moisture to the surface, consists in injecting the bowels with 
warm water ; not with a view to the evacuation of their contents, 
for we will suppose this to have been effected, but as extending the 
application of warmth and moisture to the skin,— to a surface which 
is continuous with it, and with which it has so lively a sympathy. 

I know^ a gentleman who laboured under what seemed to be 
one form of the influenza of last winter; the chief symptoms 



415 



being pain and determination to the head, with pain and sense of 
constriction across the chest. Purging and sudorifics, with careful 
diet, did very little more than mitigate the symptoms : enemata 
and vapour baths were tried separately, with about the same effect. 
The worst night he had, and during which his head was very pain- 
ful, and the skin remarkably dry, the kidney secreted sponta- 
neously an unusual quantity of urine; still he remained in an 
indifferent state. I recommended him, under these circumstances, 
to give himself a copious enema of warm water, and immediately 
after a vapour bath, and then to go to bed, as he had done before. 
The conjoined influence of these measures threw him into a most 
profuse perspiration, and he arose in the morning comparatively 
well ; and, although he was some days before he was quite reco- 
vered, yet no other measures, nor even the repetition of these, were 
necessary, — his attention being confined to the regulation of the 
bowels by the enema, and a common plain diet. There are many 
other points in connection with determination to the surface, pro- 
duced by applications directed immediately to it ; but those men- 
tioned here are of chief consequence in active inflammation, and I 
cannot do more without a digression, which in this place would 
be improper. 



OF MERCURY, AS EMPLOYED IN THE TREATMENT OF 
INFLAMMATION. 

The advantages of employing mercury in cases of severe or 
dangerous inflammation, and especially in combination with some 
narcotic, is too familiarly known to render it necessary that I 
should dwell much on that circumstance merely. The most effi- 
cient form in w4iich this remedy is administered, is the combination 
of calomel and opium. Other milder preparations are occasionally 
used, such as the blue pill in combination with the extract of 
henbane ; and doubtless there are cases in which this form is bene- 
ficial ; but I am now speaking of severe inflammations, and in 
such I would advise you to employ calomel and opium, in pre- 
ference to any other combination of mercury with narcotics, both 
as being more certain, more speedy in its effects, and, prescribed in 
doses appropriate to the peculiarities of the case, equally safe. 

The obvious power of this medicine (I speak of calomel and 
opium) in suspenduig inflammatory action, and in producing the 



410 



removal even of its products, though in many other cases a 
matter of tolerably safe inference, is no where so demonstrable as 
in the eye, where these things may be seen. 

In the eye, which is still regarded by many as having some- 
thing peculiar in its diseases, we not only have a beautiful and 
instructive microcosm, in which we may observe the various phe- 
nomena of inflammation in a manner which we can do no where 
else, but inflammation of this and other parts mutually reflect 
light on each other ; so that we can hardly arrive at enlarged and 
correct views of either without investigation of both classes of 
phenomena. Therefore, to suppose that there is any thing peculiar 
in diseases of the eye, as to their nature, is not only a very gross 
error, but a very mischievous one, and can really onlj' be entertained 
by persons whom the very idea proves to be ignorant of the subject. 
We see, therefore, how little chance a ?nere oculist has of arriving 
at a correct knowledge of the diseases of that organ to which he 
professes to limit his attention ; since such limitation may be said 
in itself to exclude the possibility of his having the knowledge ne- 
cessary, as I hope to shew more especially if I have to treat of the 
diseases of this organ. 

If diseases of the eye ha^-e any thing peculiar to the pathologist, 
it is in the facility and clearness with which thej' instruct him ; 
for whether we regard the physical characters of inflammation, its 
causes, or the various conditions of the health with which they are 
connected, we have nothing approaching, in regard to other parts, 
to the clearness and unequivocal nature of the evidence afibrded 
by diseases of the eye : and hence it follows, that, if their treat- 
ment have any thing peculiar, we must look for it simply in that 
facility necessarily afforded in the selection of our measures by the 
unusually clear manner in which we perceive the seat and nature 
of the disease. In the eye, then, we see the lymph deposited by 
inflammation becoming absorbed under the influence of mercury 
in a very curious and satisfactory manner, and the relation of 
cause and eff"ect, with a constancy which enables us to predict the 
success of the measures employed with an uniformity and certainty 
which, though not wholly without exception, is still such as to be 
rarely observable in regard to medical treatment. 

Now it is necessary that you should have correct notions, not 
only in regard to the mere fact of the absorption of lymph thus 
deposited, but also in regard to the principle on which it takes 
place ; and the reasons which shew that principle to be really the 



417 



modus agendi of the remedy. As we know that the Ijraph is re- 
moved bj the absorbents, it certainly was not an unnatural suppo- 
sition to refer the action of the mercury to some direct influence 
which is exerted on the vessels ; but a little consideration will shew 
you that this view of the matter is erroneous, and points out in 
the sequel how important the perception that it is so. Now the 
absorption of deposited matter depends on the arrest of inflamma- 
tion ; the actions leading to such depositions ceasing, the deposited 
matters are removed, as being unnecessary or noxious. If I break 
up a cataractic lens, and take care to prevent inflammation, the 
lens becomes absorbed without any remedy whatever. 

Again, in the cornea of the eye we observe very considerable 
opacity, consequent on inflammation becoming renewed, when the 
inflammation has been thoroughly checked in due time, although 
no mercury may have been employed. The thickening of parts is 
also pretty generally removed when the inflammation has been 
stopped in reasonable time, and without any employment of mer- 
cury. In fact, the inflammation having been subdued, we actually 
find that the absorption of thickened parts is rather expedited by 
friction and other measures, which would rather excite the vessels 
than otherwise ; shewing that the presence of inflammation is the 
real obstacle to absorption, and that nothing short of it is necessa- 
rily preventive of such absorption. 

I recollect a very interesting case, in which a very considerable 
opacity of the cornea became removed in consequence of a fresh 
attack of inflammation ; the cornea, in the situation of the opa- 
city, going into ulceration ; and, on the inflammation being 
arrested, the ulceration healing without any opacity at all. A 
circumstance which has favoured the erroneous idea that mercury 
acts by some specific power on tlio absorbents, is the emaciation, 
greater or less in different cases, attendant on the administration 
of this mineral. But this is easily explicable on other grounds : — 
in the first place, the cases always imply a very scanty diet ; the 
effect of mercury thus given, is to impair, in a greater or less de- 
gree, the functions of the digestive organs ; whilst secretion, espe- 
cially that of the skin, is increased instead of being diminished. 
Thus we have continued expenditure with deficient supply : but, 
besides tliis, there are very few medicines, and still fewer diseases, 
in the sense in which we use that term, which do not alike di- 
minish the bulk of the body ; and for two reasons,— one or both 

E E 



418 



of which apply to all diseases, — -viz. the diminution of food, which 
is necessary ; and the absence or diminution of the powers of assi- 
milation, through which only it can be converted to nutriment. 

The power, then, which mercury exerts in inflammation, is 
proximately due to the influence it exerts on the minute blood- 
vessels of the part, or the increased action on which the products 
of inflammation primarily depend ; and thus, though inflammatory 
action ceases, the absorbents are left to the unembarrassed exercise 
of their natural disposition, which is to remove all . depositions 
which are not necessary, and the causes of which have ceased to 
operate. But we gain very little by this step in the investigation, 
if we use it not as a means to a further progress in the enquiry. 
The interesting question is not, abstractedly, whether mercury 
influences the minute vessels of the part, but how it exerts this 
influence : and now we arrive at the really important question. 
Here, as in all others, we must begin by collecting facts. Now- the 
first fact is, that mercury, made to produce those eflects which I 
have mentioned, must be administered so as to " affect the con- 
stitution," as it is termed. What is meant by " affection of the 
constitution?" Wh}^, generally, certain altered conditions of the 
system, which we familiarly recognize as the effects of that mi- 
neral. And what are the effects? Soreness of the mouth and 
salivation is one of them ; and so characteristic is this, that the first 
question a surgeon asks, with a view to ascertain the existence of 
this constitutional effect, is — have you any disagreeable taste in 
your mouth, sir ; are your gums sore ? He inspects these parts ; 
and if he see an elevated, vascular condition of the gum, he regards 
the constitution as affected by the mineral. 

Now, practically, there is no great objection to such a test, if 
certain fiicts be remembered at the same time : — first, that in many 
patients this particular effect can scarcely be produced ; in none, 
abstractedly regarded, is it nec^^^sary. Another fact is, that mer- 
cury affects the skin in an especial maimer, increasing its secre- 
tions ; as also, usually, those of the kidney and bowels ; the pulse 
too becomes softer, though, so far from being less frequent, its 
frequency is generally increased ; w^hich is a circumstance you will 
bear in mind as important in this agency : for although the fre- 
quency of the pulse may be increased, we do not find that its force 
is increased ; on the contrary, it has rather a tendency to diminu- 
tion. Now, in considering these facts, in relation to mercury, the idea 



419 



first suggested, might be that it acted by a depleting iuflueiit;e, iu 
that it increased the various secretions : but we very soon perceive 
that the idea is not tenable ; because, in the first place, many reme- 
dies increase the secretions much more remarkably than mercury, 
without effecting any thing like so certain a control over inflam- 
matory action. 

Besides, such increase of secretion is so far from contributing 
to the good effects of mercury, that it almost certainly produces 
failure ; and, as the bowels are the most certain channel through 
which mercury produces the largest depletion, we at once stop this 
by combining the exhibition of opium, that the mercury may not 
" run off by the bowels." But, in regard to the sldn, we observe 
no such ill effects from the mercurial excitement of its secretions, 
and therefore we do nothing to check this : for, besides that opium, 
in certain doses, is actually a sudorific, we even, on many occa- 
sions, combine medicines with the mercury which have a very 
powerful effect on the skin as their leading character, not dreaming 
of vitiating the effect of the mercury thereby, unless these addition- 
al remedies affect (which they will sometimes do) the bowels, when 
we instantly discard them : of this the tartar-emetic is an example. 

But again, it might be said, that if the mercury acts thus on 
the skin, may it not still owe its anti-inflammatory agency to de- 
pletion ? There is a very simple reply to this query, which ap- 
pears quite conclusive in the negative. The answer to the question 
regarding the influence of depletion in general, applies with the 
same force to the skin in particular. Since, if it were so, we should 
find that the benefit would be commensurate with the excitement 
of the skin ; which is by no means the case. Many remedies pro- 
duce more abundant secretion from the skin than mercury does ; 
tartar-emetic, for example : and although such excitement is to be 
regarded as beneficial, yet it v^ill not stand in the place of mercury 
in the cases to which this remedy especially applies. 

It is the sustained manner, not the abundance of the matter 
secreted, which constitutes its essential effect, if it is to be success- 
ful. The additional force given to the action of mercury by the 
avoidance of all depressants at the surface, as cold, is an unanswer- 
able argument in favor of its effects being mainly attributable to 
its influence on the surface of the body. Neither can we attribute 
the action of mercury to any general reduction of power, and 
through this, of the power in the inflamed part ; for, besides that 
repair implies the necessity of at least as much power as injury 

E E 2 



420 



does, we find this remarkable fact — that of all secretions (the pro- 
portion being the same), the increase of that of the skin pro- 
duces the least debility. 

So again, of all remedies, mercnrj, which, to say the very least 
of it, yields in anti-inflammatory action to none-— if, indeed, it be 
not superior to all others — is that which produces the least debility 
or depression of power. There is, in truth, no comparison in this 
respect, if we think of it in relation to the vigorous employment of 
bleeding, purging, or any other of the general measures mstituted 
for the relief of inflammation. Therefore the conclusion seems 
irresistible, that mercury acts by equalizing the circulatiou, or by 
determining to the surface, which, in the majority of cases, is the 
same thing ; and thus destroys the element essential in all inflam- 
mations whatever, — namely, unequal circulation, — that is, conges- 
tion in the part inflamed. 

The consideration also of the phenomena with which inflam- 
mation commences, lends the strongest conceivable probability to 
this view of the action of mercury : and I allude especially to the 
occurrence of coldness or shivering, so constant a precursor to in- 
flammations of external parts. Nor is it material, that, in so large 
a system as the w^hole vascular tissue of the body, inflammation of a 
minute spot, like the iris, for example, should occur without this pre- 
vious testimony of depression at the surface having been perceived ; 
especially when we consider, in regard to light and transient im- 
pressions, how different the nervous susceptibility of different per- 
sons is, both in regard to their abstract sensibility to impressions, 
and the degrees of that sympathetic vigilance between different 
parts on which the early recognition of disorder essentially de- 
pends*. How mercury produces this determination to the surface, 
is another question, and one of great interest. When we consider 



* The great difference in the vigilance, so to speak, in the sympathies, is very 
remarkable, both of mind and body. I last year had a case of chimney-sweeper's 
cancer, which, when presented to me, seemed to have extended so deeply towards the 
pelvis, that I regarded any attempt at its removal as im olving little certain but 
additional suffering. I told the friends of the patient that, as he would surely die 
without an operation, 1 would not hesitate to undertake its removal, provided any 
surgeon would say it was a feasible thing. Mr. Stanley saw it, but agreed with 
me that the thing was too desperate to justify a trial. His friends informed him 
of all this ; and the man suffered great pain from the disease, and wished its re- 
moval at all hazards ; but as I could not conscientiously undertake it, I declined 
doing so. Now, with all this, I could not but be struck with the apparent indiffer- 
ence of the man's mind to his situation ; for it was evidently neither the result of 



421 



how often inflammation depends on remote, and, as I call them, 
real causes, referring to disordered condition of some one of the 
various viscera ; and consider again the effects which mercury has 
on these viscera, in cases where inflammation may or may not be 
present ; we cannot but regard the possibility that it may act on 
the surface by its power over some viscus on which the inflam- 
mation may depend : but then we should, I think, expect secretion 
from that viscus ; which either does not take place, or is not per- 
ceptible in every case. Its determination to the surface might 
probably be more safely referred to a more general law in the ani- 
mal oeconomy. It is itself a poison, and one highly capable of 
injury to the animal oeconomy. The slow and less exciting in- 
fluence which has led to the inflammation may not have been 
sufficient to rouse the powers of the animal oeconomy, weakened 
by habitually embarrassed function, and accustomed to some in- 
jurious influence; but a very injurious agent or poison being in- 
troduced, having an influence short of annulling natural power, 
excites endeavours at its expulsion ; and then the oeconomy does 
it in the natural way, — that is, by actions at the surface : which 
actions, equalizing the circulation, destroy the element of inflam- 
mation, as I before stated (congestion) ; and that thus, after all, the 
effects of mercury may in fact he only those exerted by many other sub- 
stances, injurious or poisonous to the animal oe,conomy. That the 
mercury is partly thrown off by the skin, we have incontestible 
demonstration in the chemical changes on metals which it 
produces. 

However, these latter considerations may be regarded per- 
haps more safely, at present, as matters in abeyance, and food for 
further reflection. It is certain they point to matters of the highest 
import; and it would only accord with the simplicity of Nature, 
if, through the contemplation of violent diseases, and violent or 
poisonous remedies, we arrived at nothing less than the perception, 
that all diseases and all successful remedies had but one, or at 
most two, modes of action, — viz. determination to the surface and 
equalization of the circulation ; and unsuccessful actions or reme- 
dies destructively poisonous but the contrary of these conditions. 



great courage nor of resignation, but a peculiar indilference, such as we see in 
trifling maladies. Yet I have often removed the same disease where the whole 
nervous sj^stem has been as active in its suffering and its apprehensions as in any 
malady whatever. 



422 



Premising, then, that the tendency of mercury to equalize the 
circulation is so universally admitted, that we often employ it with 
no other view in cases where no inflammation exists, I shall, as re- 
gards its action in inflammatiou, subjoin the following propositions, 
not forgetting to add the mode of its administration. Hereafter I 
shall resume the consideration of mercury ; in relation to which I 
have facts of great value, as throwing light on the use and abuse 
of this mineral, not only in inflammation, but in various other 
disorders. It appears then — 

1. That mercury acts in inflammation by its power of equal- 
izing the circulation, and this, by determining to the surface of the 
body, to which, if the equilibrium be still disturbed, the excess of 
action is transfen-ed. 

2. That the tendency of mercury to equalize the circulation 
in all cases where its equilibrium is disturbed, is universally 
acknowledged. 

3. That equalization of the circulation is obviously destructive 
of that determination of blood which is a necessary element in all 
inflammations. 

4. That restoration of equilibrium appears to be the essential 
remedy in inflammation, be the equilibrium restored by w^hat mea- 
sure it may. 

5. That, therefore, this view of the modus ayendi of mercury is 
remarkably in harmony with all the facts of the subject, and es- 
pecially with that which it is the object of the preceding pages to 
establish. 

6. Because, whilst there seem to be no facts impugning these 
views, the phenomena are reconciieable with no other. 

As to the administration of this remedy in inflammation, I have 
already observed that calomel in combination with opiam is the 
best form for its administration ; and, generally, about two or 
three grains of calomel w^ith half a grain of cpium is the propor- 
tion : this being given every three or four hours until the system 
be affected, or until (which is the best proof of it) the inflammation 
begins to subside. We then lower the dose by giving it at longer 
intervals, by diminishing the quantity, or by both : and in some 
cases, where the ptyalit-m is severe, we relinquish the mercury 
altogether ; experience shewing that the efi'ect of the mineral is 
sustained, in many such cases, for a considerable time after we have 
ceased to administer it. 

In cases where the opium appears to affect the head, or, at flrst, 



423 



and before the mercnrj produces its peculiar effect, it produces 
excitement, or diminution of secretion, we lessen its quantity. 
Where the calomel, on the contrary, affects the bowels, we increase 
the quantity of opium ; but not by more than a quarter or half a 
grain, at the utmost, at a time : and in some constitutions, where 
there is evidence of deficient power, one grain of calomel and 
one-fourth or one -sixth of a grain of opium may be sufficient for 
a single dose. In other cases, on the contrary, where there is 
good power, and the inflammatory excitement is urgent, we give 
even larger doses than that first mentioned ; but it is generally ne- 
cessary, if we increase the calomel, to increase the opium also, and 
vice versd. Children are not so readily affected by mercury, in 
proportion to their age, as adults ; yet if they become suddenly or 
severely affected, the consequences are usually more serious, 

I know of one case, where the child of a medical man becom- 
ing seriously influenced by mercury, extensive sloughing took 
place, and the child died. A very good mode of administering 
mercury in children, I mean where we wish to " affect the consti- 
tution," as it is termed, is by combining two or three grains of the 
hydr. c. creta with a grain or two of Dover's powder ; and this 
given every four or six hours, according to circumstances. 

I shall have a great deal to say on the subject of mercury in 
respect to the various intentions with which it is administered ; but 
such observations as are of general application I should mention 
here. 

Generally, the peculiar effect of mercury on the constitution is 
gradual ; so that we are apprised of its action becoming general by 
certain signs w^hich enable us to preserve and prevent unnecessarily 
violent or untoward consequences. Thus, we find the pulse becom- 
ing softer, perhaps accelerated ; the skin exhibiting habitual, but 
perhaps gentle, moisture ; perhaps some increase in the urinary 
secretion ; the breath begins to exhale a peculiar odour, seldom 
perceived but as the effect of this mineral ; the patient has a dis- 
agreeable, coppery, or otherwise metallic taste in the mouth ; the 
gums appear more vascular and somew^hat elevated. These signs, in 
various degrees, or in different combination, warn us that the mer- 
cury has affected the system, so that we begin to diminish the doses 
accordingly : but it must be remembered, that occasionally a 
very violent evidence of mercurial action occurs very suddenly : 
thus, in the evening the patient may exhibit little if any indica- 
tions of the mineral, and yet, in a few hours, the characteristic 
evidences of it may occur with unusual violence, and far exceed- 



424 



ing our intentions or wishes. This is certainly not common when 
mercury is judiciously given; but still, as it does happen, we must 
be alive to its possibility ; and, in cases where an increased dose 
becomes necessary, be satisfied with cautious and reasonable aug- 
mentations of it. 

An example of this happened once in my own practice. The case 
was watched with the utmost vigilance ; and, although the patient's 
sj'Stem was somewhat tardy in its recognition of the mineral, yet 
the doses were only those usually given : nevertheless, in a single 
night, salivation came ou in so severe a degree that I never saw an 
instance like it. The patient ultimately did well, both as to the 
mercury and the inflammation for which it was administered ; but 
I was very anxious, fearing for many days that the tongue, which 
hung out of the mouth in the form of a swollen, yellow mass, 
would slough. At present, in inflammation, we make the digestive 
organs, as you perceive, the portals through which we convey 
mercmy into the system. This method has some advantages and 
some objections, the adjustment of which requii'es a more refined 
analysis of the causes of deep-seated inflammations, as occurring 
in different individuals, than has been hitherto made. But if there 
be any truth in the principles I have unfolded in regard to inflam- 
mation, the path is now opened auspiciously for such an extension 
of our knowledge : wherefore, as the other modes of afi'ecting the 
constitution by mercury do not, at presenty apply to the treatment of 
inflammation, I shall here conclude my remarks on the use of mer- 
cury, so far as it belongs to the general treatment of inflammation. 

I have thus endeavoured to place before you, in the plainest 
manner I can, the object to be kept in view in the general treat- 
ment of inflammation ; and the best manner in which, according as 
your perception of its cause is clear, imperfect or unattainable, 
such objects are to be accomplished. 

It follows, that the grand desideratum will be the equalization 
of the circulation ; as this is not only opposed, but antithetical to, 
and inconsistent with, that determination to a part, without which 
inflammation appears impossible. 

That the main point, paramount to all others, is the discovery of 
the particular organ in which the cause of the inflammation resides, 
which will very commonly be found not in the organ inflamed. 

That this principle applies with equal force to inflammation 
generally, and those dangerous extensions or modifications of it 
which supervene on local injury. 

That, generally, whilst all beneficial proceedings act by equal- 



425 



izing the circulation, quoad the inflamed part, so all attempts at 
this appear most auspicious, as they determine, in a practical 
sense, to the surface of the bodj. 

That where, from the impossibility of perceiving the real cause, 
as distinguished from the exciting cause of the inflammation, we 
cannot direct our measures to a particular organ, but where we 
are obliged to endeavour to effect our objects by means of a gene- 
ral kind, a summary of the general treatment will be as follows : — 

1. Rest of both mind and body generally, and of the part in 
particular. 

2. Abstinence. 

3. To empty the alimentary-canal*. 

4. To promote its secretions in the manner and on the condi- 
tions spoken of under the article "Purgatives." 

5. The use of tartrate of antimony, both in regard to its pecu- 
liar effects, and as furthering those sympathetically induced by the 
actions of the alimentary canal. 

Bleeding in the various ways, in different eases ; regarding this, 
however, with the exceptions referred to, as the remedy which it is 
desirable to avoid, as one which ministers more to the effects than 
the causes of inflammation, and one which, in a more enlarged 
state of our knowledge, will, the case of " absolute general plethora 
excepted," at no distant period cease to be necessary. 

Determination to the surface by counter -irritation, &c., vapour 
baths, &c., the latter being probably of still greater importance 
than we commonly believe. iVnd if the inflammation be severe, 
far advanced, or threatening, the prompt administration of calomel 
with opium, as the most potent of all remedies yet discovered, in 
equalizing the circulation, regarded in a general sense. 

In general, the order in which these remedies should be employed 
will be that above stated ; but this will necessarily be modified by 
the description of the case, and the period at which we are called 
on to treat it : but, in all cases, intervals of longer or shorter dura- 
tion are to be allowed between the various measures, according to 
the severity of the case, in order that as great an approximation to 
inductive reasoning may be kept in \aew as is safe and practicable ; 
and that cases which require the absolute, simultaneous employment 
of so many measures as are generally adopted, are exceedingly rare. 

* I do not here mention emetics ; the use of these has been referred to in treat- 
ing inflammation, by ministering to its real causes, and the more modified effect of 
this class of remedies in the remarks on tartrate of antimony. 



426 



DISCOURSE XI. 



ox ERYSIPELAS. 



Ix conducting the argument on inflammation, I have been 
obliged more than once to speak of erysipelas, and to mention those 
cu'cumstances by which it is characterized, both locally and consti- 
tutionally. In erysipelas, vre observed that the redness and swel- 
ling are always more or less diffused : we cannot perceive any well- 
defined line separating the affected parts from those which jet 
remain sound ; but the redness and swelling become insensibly 
shaded off", as it were, until we arrive at the sound parts. Usually, 
the swelling extends beyond the redness ; and, whilst the red parts 
are elastic, those swollen without being red will not unfrequently 
pit a little on pressure. If we make a little pressure on the red 
parts, the redness disappears for a moment, but speedily returns 
when the pressure is withdrawn. These appearances usually pre- 
sent themselves at first in a small district, whence they extend with 
greater or less rapidity in different cases. In some, they reach in 
a few hours the extent which they are to occupy. In other cases, 
two or three days may intervene, — the erysipelas being at times 
stationary, or slowly extending during this period, and ultimately 
occupying the whole limb. Generally, we observe that the degree 
of swelling bears some proportion to the extension of the erysipelas ; 
but occasionally we observe the swelling occup_^ing a large district, 
whilst th^ redness may be confined to one comparatively small. 
The seat and progress of erysipelas are different in different cases : 
sometimes the skin only is affected, and this very superficially ; at 
others, the cellular tissue beneath it, or even the fascia beneath that 
agam. In the sevrver forms, the intiammation generally commences 
in the cellular tissue beneath the skin ; the fascia beneath it and 
the skin above participating more or less, according to the vehe- 
mence of the inflammation. When erysipelas thus commences in 
the cellular tissue, the fascia is sometimes little affected, whilst the 
skin is always, in a greater or le^s extent ; that extent seldom, how- 



427 



ever, being commensurate with the inflammation of the cellular 
tissue beneath. The progress of erysipelas also varies ; sometimes 
it creeps from one part of the skin to another, retiring from those 
parts first occupied bj it (erysipelas erraticum) ; sometimes it ex- 
tends from the original site in a continued form, still affecting only 
the skin, and that superficially (erythema) ; and it either retires, 
simply producing a desquamation of the cuticle or scarf skin, or 
lea\'ing, in some cases, a kind of ulcerated, in others scarcely more 
than a raw, surface, which quickly heals. 

These, however, are in general light cases : the erysipelas which 
surgeons are called on to treat, and which they generally intend by 
the term, is a more serious affection, and presents, both in its cha- 
racters and progress, the features of severe inflammation. The 
inflammation extends more or less rapidly from the site it first 
occupied, often involving the whole limb. There is extensive red- 
ness ; sometimes a tint of yellow ; great swelling ; and, this con- 
tinuing, the skin may either slough or ulcerate, discharging the 
products of an imperfectly developed suppuration ; that is, matter, 
some of which may be well formed or healthy-looking, with other 
portions of an unhealthy character, or mixed with blood and 
sloughy cellular tissue ; or the whole process may be, in its leading 
features, of a sloughy character, large portions of skin or cellular 
tissue, or even fascia, being thrown off in a shreddy or otherwise 
decomposed or altered condition. When sloughing, either in a 
great or a more measured extent, is to take place, vesications fre- 
quently arise on the surface, the skin beneath them exhibiting a 
dark fiery -red, a yellowish, or even a blackish, colour ; and, if all 
this is to happen, the general colour of the inflammation is found to 
be of a darkish-red, approximating to the colour of the venous, 
rather than arterial, blood. In all cases of this form of erysipelas, 
we observe a strong tendency to mortification ; so that we can 
hardly say that this kind of erysipelas ever terminates, properly 
speaking, in suppuration. For, although there be frequently enough, 
perhaps generally, some pus formed, yet it is often unhealthy in 
character. We find it mixed with firagments of sloughy cellular 
tissue, blood, and more or less sloughing of the skin. Instead of 
proceeding from a circumscribed cavity, the pus comes obscured 
by a variety of different appearances, the result of inflammatory 
action or effusion, from an irregular district of boggy cellular tis- 
sue. This is the case we call phlegmonoid erysipelas. The. con- 
stitutional disturbance varies in different cases; but it is generally 



428 



severe. The complaint is preceded or accompanied by sensations 
of cold or shivering ; an inflammatory excitement supervenes ; the 
pulse becomes frequent, sharp, and bounding (not often hard, I 
think) ; there are thirst, dry or foul tongue, want of sleep, often pain 
in the back or head, or both, and all the symptoms of fever ; loss , 
of appetite, and almost always a vitiated state of the secretions ; 
the bowels are generally costive ; but to this there are exceptions. 
If the erysipelas is to proceed, this state of disturbance soon be- 
comes still more alarming : the brain becomes disturbed ; the pulse 
falters in its power, whilst its frequency is continued, or even in- 
creased ; the patient becomes delirious ; there is a dark state of 
tongue, sometimes red and dry, but soon becoming black; often 
involuntary twitching of the muscles ; and death closes the scene. 
In other cases, the fever, having reached almost any height, is found 
gradually to subside ; the tongue becomes moist and clear ; the se- 
cretions natural ; and the patient recovers ; regaining his strength 
more or less rapidly according to the natural powers of his consti- 
tution, the severity of the attacks, the treatment employed, and the 
extent of parts requiring repair. 

There is a considerable variety observable in the severity of 
febrile disturbance in erysipelas ; nor is this always commensurate 
with the degree of local mischief. Examination of the abdomen 
will sometimes detect tenderness in some part of this cavity, and 
not unfrequently in the region of the liver. There is also great 
difference observable in the pain experienced by the patient. In 
some cases, it is very trivial, or rather a sense of heat or itching, 
or both ; in others, the pain is very acute, and, occasionally, ex- 
tremely severe. Nor are these varieties always proportionate to 
the degree of inflammation. 

NATURE OF ERYSIPELAS. 

Could we understand all Nature's processes alike, it is pro- 
bable that they would all be equally interesting ; but, as our capa- 
cities on the one hand, and our misdirection of them on the other, 
are found practically to limit our perceptions comparatively to a few 
of such processes, it appears to me, that, of all inflammations, no 
one, singly considered, is so instructive as erj^sipelas ; for that it is 
an inflammatory disease, is so generally admitted, and, what is 
still more to the purpose, so demonstrable, that I need not at this 
day moot that question. 



429 



Occupying a position, as it were, between more health j inflam- 
mation, and those which are either still further removed from it, 
or attended, as in the case of gout, with a sort of mysterious pecu- 
liarity, erysipelas enables us to connect, in a continuous chain, 
inflammatory actions apparently so different from each other, that, 
were the link it affords absent, this connection would present diffi- 
culties which might reasonably be expected to prove insuperable. 
I have already availed mj self of this connection. If you will only 
contrast gout, for example, either in its local or constitutional fea- 
tures, with common or healthy inflammation, you will perceive 
what an appai-ent gulph there is betwixt them ; they, in fact, appear 
to have but few things in common : but, if you now place between 
them the various examples of erysipelas, and those inflammations 
alHed to it in character, you are not only enabled to trace the chain 
very easily, but you find that the various links are so interwoven 
with each other, as it were, that you ultimately discover those dis- 
tinctions which your nomenclature implies, to be essentially 
artificial, and that they really apply only to the more marked ex- 
amples of the varieties to which they refer. x\s I am desirous of 
inculcating enlarged views, I would observe that these connections 
between different diseases are by no means restricted to those we 
call inflammatory ; and, so far from being sources of difficulty, 
become, when properly considered, not only highly useful, but an 
essential element in all investigations by which we can hope to ar- 
rive at a real knowledge of disease. To those who attach such 
value to nomenclature as to consider that medical science can be 
advanced by an attempt to give every disease a name, such gradual 
shadings off in diseased actions will, of course, always prove 
sources of insuperable difficulty ; but, without meaning to argue 
that a well-adjusted nomenclature is of no use, it is perfectly cer- 
tain that a knowledge of disease is an indispensable preliminary, in 
any endeavour at a nomenclature which can be rendered available 
for scientific purposes. A very mischievous error, in the present 
state of medical science, is, that so much of the nomenclature is 
founded on circumstances not essential to the disease ; so that dis- 
eases, essentially the same, have different names applied to them ; 
whilst diseases, often depending on very difi'erent causes, have 
the same name. Cardialgia, gastrodynia, pyrosis, are names 
drawn from symptoms wliich are common to many disorders ; 
whilst the whole nomenclature of diseases of the skin abounds 



430 



with the contrary ; that is, different names applied to diseases es- 
sentially the same. 

But the importance of those gradations, in leading us to the 
interpretation of Nature, is not seen even when extended to dis- 
eases generally. We find that in all the kingdoms of Nature, 
whether regarded as matters of mere scientific research, or as a 
step to the sublime truths of natural theology, it is through the 
relations thus established that we are enabled to understand any- 
thing. It is, in fact, by such means that we perceive those connec- 
tions unfolded in comparative anatomy ; that we discover the 
" connection of the sciences;" and, ultimately, that of the whole 
creation with all parts of it. 

Before proceeding with erysipelas, I should mention one or two 
points in its nomenclature. Erysipelas following a wound is 
sometimes called traumafie erysipelas ; when occuning without a 
wound,' it is sometimes termed idiojjatliic ; when the pre^-ious dis- 
turbance is well marked, it is sometimes called symiptomatic ; some- 
times the inflammation is accompanied by unusual extent of swel- 
ling, indicating extensive effusion in the cellular tissue, far beyond 
the inflamed part, with pitting on pressure, sometimes called 
oedematous erysipelas ; then there is the phlegmonoid erysipelas, 
already spoken of (erysipelas phlegmonoides). There is no essen- 
tial difference in these cases ; the general nature of the disease is 
emphatically the same. 

I must now observe to you, that two things in regard to ery- 
sipelas are admitted on all hands ; first, its inflammatory nature ; 
and, secondly, its invariable connection with a pre\dously distm'bed 
state of the animal oeconomy. I may add that it may occur as a 
sequence on local injury, or without any perceptible injury of this 
kind whatever. The admission of the inflammatory nature of 
erysipelas does not, however, always lead an author to recommend 
the treatment usually addressed to inflammation. The admission 
itself is sometimes rather implied than acknowledged : thus INlr. 
Pearson (Principles of Surgery, p. 187) says, that he regards the 
relation of erysipelas to inflammation ^' as very remote."' He also 
(on Treatment) says, that gentle aperients, the determination of an 
equable circulation to the surface of the body, &c. are the principal 
measures ; that powerful evacuants are often miscliievous ; and, of 
bleeding, that, " in large towns, cases seldom occur in which it is 
necessary or even admissible." He also recommends the free divi- 



431 



sion of parts where erysipelas follows on wounds, &c. After 
stating what he conceives to be the more common causes, he says 
that they will be influenced " by the state of the system." You 
have already seen that the older surgeons, as Wiseman and Heister. 
recognized the connection of erysipelas with a disordered condition 
of the system ; and that CuUen does also. 

Dessault, one of the best practical surgeons France ever pro- 
duced, recognizes the connection of erysipelas with disordered 
fanction, and speaks particularly of a "bilious erysipelas;" and 
he says, in another place (see CEuvres Chirurgicales, par Bichat, 
t. ii, p. 583), generally, " c'est surtout a Tetat primitif des pre- 
mieres votes qu'il faut faire attention pour les placer dans celle qui 
leur convient." 

Lassus, in his Pathologic Chirurgicale, tome i, p. 8, speaks 
of plethora, suppression of habitual discharges, disorders of the 
biliary secretions, undigested aliment generally, and particular sub- 
stances taken into the stomach, as causes of erysipelas." He re- 
commends emetics, purges, and blisters. 

Baron Boyer, after saying, of erysipelas, that it generally occurs 
from internal causes, says that, although these are often unknown, yet, 
from the good effects of emetics and light aperients, "on sera tente de 
croire que cette cause a ordinairement son siege dans les premieres 
voies," &c. ; besides w^hicli general recognition, he states, as causes 
of erysipelas, obesity, bad habit of body, gross food, high meat, 
excess at table generally, the abuse of spirituous or fermented 
liquors, and many others, implying a disordered condition of the 
body. Bleeding, he says, is not often necessary, and should be re- 
gulated by the powers of the patient previous to the attack : he 
appears, however, partial to bleeding in phlegmonoid erysipelas. 

Mr. Copeland Hutchinson, in the fifth volume of the Trans- 
actions of the Medico-Chirurgical Society, in recommending inci- 
sions in erysipelas, attributes the alarming nature of the cases 
which had come under his care to " the intemperance and expo- 
sure to frequent and sudden changes of climate" to which the pa- 
tients (seamen) are exposed. He seems to have adopted local 
bleeding only, except that consequent on the incisions, which 
"yielded," in general, from fifteen to twenty ounces. His other 
treatment consisted of aperients and sudorifics, and bark, as recom- 
mended by Dr. Wells and Dr. Fordyce, after the reduction of the 
inflammation. He says also, that, " for the last five years, by the 
treatment" ("incisions"), " he had not lost a case," &c. 



432 



Mr. Lawrence, in a practical Essay on Phlegmonous Erysi- 
pelas, in the fourteenth volume of the Transactions of the 
Medico- chirurgical Society, and of which I shall speak more pre- 
sently, very plainly describes the connection of this disease with 
constitutional causes. He says, speaking of the causes of the dis- 
ease, that " the habitual excitement of the vascular system, or the 
long-continued disturbance of the stomach, alimentary canal, and 
liver, consequent on intemperance or excess, lay the foundation of 
iriflammation generally; and it depends on individual peculiarity, or 
on local causes, whether the skin or other parts shall be the seat of 
disease. In most cases of erysipelas, the biliary and digestive sys- 
tems are more or less actively disordered ; such disorder appearing 
sometimes to produce the cutaneous alfection, sometimes to be ex- 
cited sympathetically by it." And, in commenting on the division 
of Dessault, of bilious, as contradistinguished from phlegmonous, 
erysipelas, Mr. Lawrence remarks — " on which division it may be 
observed, that the symptoms called bilious are commonly found 
also in the phlegmonous cases." — Op. cit. p. 37. 

I have given you a few quotations from different authors, to 
shew that, notwithstanding the differences of opinion on points 
more or less important, as the case may be, evinced by different 
writers, yet that they all agree in the recognition of the connection 
of this complaint with previous constitutional disorder ; and, whilst 
on many points they differ so much, that a statement of the seve- 
ral opinions would occupy far more space than that necessarily 
allowed for the whole of this discourse, and be, as I believe, very 
unprofitable, it will be of more use briefly to state the points on 
which they agree. Thus, whatever they may think as to the closer 
or more distant alliance of erysipelas w^ith common inflammation, 
they all agree in the local appearances presenting heat, redness, 
pain, or itching, and that the results are, in different cases, suppu- 
ration, more or less unhealthy, mortification, and so on. We also 
find that (whatever the opinion of one or other w^riter may be as to 
the seat of the disease) we have plenty of evidence shewing that it 
occurs, in different cases, in one or in all the structures said by one 
or the other to be more particularly involved in it. These are the 
skin, the cellular tissue, and the fascia beneath it. Again : what- 
ever difference of opinion we find in individual writers on the 
treatment particularly thought the best, we discover plenty of evi- 
dence shewing that the only point on which they universally agree 
is the existence of general disorder of the body, and attention to 



433 



the cliylopoietic viscera, in aid of the correction of this disorder, 
with the employment of measures well known to determine to the 
surface of the bodj. We therefore, so far as the conflicting evi- 
dence of all writers is concerned, will proceed in the same manner 
as we should do in regard to conflictiug evidence on any other sub- 
ject ; that is, set down as philosophically true that only in which 
they all agree. This, then, will involve the following points : 

That the local characters of erysipelas are those by which we 
ordinarily define inflammation — heat, redness, swelling, &c. 

That it is connected with some disorder of the general system. 
That the treatment always includes endeavours which have a 
tendency to correct such disorder, and also measures which have a 
direct tendency to determine to the surface. 

If to this we can add what appears to us the testimony of Na- 
ture, or if we can find even that she does nothing to contradict 
such testimony, why then we can reason on such facts in strict 
conformity with the principles of induction. 

With regard to the dependence of erysipelas on general disturb- 
ance of the constitution, I can only say, that I have examined the 
subject with all the care of which I am capable, and with no lack 
of opportunity for at least the last sixteen or seventeen years ; and 
that I consider the dependence of erysipelas on such disturbance, 
whether occurring after local injury, commonlj^ so termed, or after 
some injurious influence of another kind, acting on the body, as de- 
monstrable, in strict conformity with the rules of induction, as any 
truth in the whole rauge of natural philosophy. 

The causes of erysipelas, however, will be different in different 
cases ; but they involve general disturbance of the oeconomy in all. 
In one, impressions on the nervous system seem to be the primary 
causes of the disturbance ; in another, disorders of the stomach, 
bowels, liver, &c. In other cases, although the impression acts 
ultimately on the nervous system, we cannot trace it to causes 
acting directly thereon, but recognize it as a gradual effect, wrought 
up by continued disturbance of particular organs, the chylopoietie 
viscera more especially. Thus, persons who live irregularly or 
luxuriously, or who maintain a constant undue excitement in these 
organs, are especially liable to erysipelas. We cannot, in fact, 
always connect erysipelas with disorder of one particular organ ; 
but, in cases in which the cause is most latent, I have been led, by 
experience, to look with especial suspicion to the liver. I just 
mention this, at present, as a practical fact, without meaning to in^ 

F F 



434 



sinuate more than I say in regard to the general nature of the 
causes of erysipelas. 

In a vast number of examples, an accident, and fre(^uently one 
of a very trivial nature, is the first occasion on which disordered 
conditions of the system are manifested. So long as Nature has _ 
only to support life, the system hobbles on, as it were, under the 
influence of factitious excitement, without the occurrence of any 
manifestations which we regard as disease ; but the moment she 
receives any little shock, or especially if she be called on for any 
of that increase of exertion which is implied in repair of injury, 
the real state of the system is made manifest ; and there is a fear- 
ful exhibition of the want of power in the animal oeconomy. 

The pervading susceptibility of the nervous system, in patients 
disposed to be affected by erysipelas, since it affects the whole sys- 
tem, affects, of course, the nerves of every part, and thus renders 
many causes, ordinarily of a very trivial nature, sources of undue 
excitement. 

Now, as to the want of power above mentioned, erysipelas is 
frequently the mode in which this is exhibited ; and it is to this 
character that I wish especially to direct your attention, because it 
not only, in a great degree, explains the nature and local symptoms 
of the disease, but it is, of all others, the most useful impression to 
retain in the conduct of your treatment, be that treatment one or 
other of the various kinds which have been instituted for this com- 
plaint. It is through a careful adjustment of the question of power 
that the discrepancies in the treatment of this disease, which, prima 
facie, are so discreditable to the study of medical science, are to be 
reconciled. 

This leads us, then, to consider erysipelas as occurring after a 
wound, \vhich is commonly spoken of as a case of traumatic or 
surgical erysipelas. For this purpose, I shall suppose the most 
instructive case, which every surgeon know^s to be of frequent 
occurrence ; namely, one in which the wound has been very trivial. 
A man, free from any visible marks or even feelings of disease, 
receives a slight scratch on his finger or his skin. He takes little 
notice of it, but follows his usual avocations. The following day, 
however, he finds the v^ound become painful, and surrounded with 
redness and swelling. The redness and swelling extend to a 
greater district; then up the whole limb. He is, perhaps, shivering 
and cold ; he then becomes feverish, and feels great prostration of 
strength. The wound exhibits no attempt at repair ; the swelling, 



435 



continuing, becomes darker in colour ; spots of vesication form in 
different places ; and the skin rapidly sloughs : these sloughs ex- 
tend ; the whole limb presents various patches of mortification ; 
and the patient becomes wandering, the pulse rapid and feeble, the 
tongae dark and dry, and he sinks ; dying, in fact, in a state exactly 
resembling typhus fever. 

I have chosen this sort of case, because I would at once avoid 
the long and unnecessary discussion, which a more severe injury 
might render necessary to those who consider the subject for the 
first time, to shew that the wound, in the abstract, beyond being the 
exciting cause, had nothing to do in the real causation of these 
terrific phenomena. What, then, do these phenomena shew ? 
First, they evince great excitement ; next, great absence of power, 
and, by consequence, the important distinction which exists between 
them — a distinction of universal importance in all diseases, of 
whatever aspect or kind, as you will hereafter more clearly per- 
ceive. As regards power, the mere scratch is not healed ; large 
districts of the skin die ; and ultimately, in many cases, the patient 
sinks. There is no approximation to evidence of the healthy re- 
sources of the animal oeconomy ; but of excitement we have 
plenty. The functions of the arteries, which should have quickly 
repaired the injury, become preternaturally active ; but, instead of 
repairing, they quickly exhaust, the powers of the part ; and morti- 
fication ensues, instead of repair. 

Of the causes which disturb the system I have already spoken ; 
but, to shew how real they are, and how insidious, and how marked 
in parts in regard to which the ordinary indications were absent, I 
will cite a case or two, I do not here repeat what has been said 
as to the influence of the w^ound ; such as wounds occurring with- 
out erysipelas, and erysipelas without wounds. (See Inflammation.) 

A gentleman, about fifty-six years of age, had a large tumour 
on the neck ; it occupied a district extending from beneath the 
ear, which it had thrust upwards, to a considerable way down the 
neck ; in size, it was about as big as a large orange. On examina- 
tion, it appeared not very tightly connected to the subjacent parts ; 
but still it had not that freedom of motion which was desirable. 
He had consulted Mr. Cline, Sir A. Cooper, and Mr. Abernethy, 
some years before I saw him : the opinions not being very decided 
in either ( ase, nor exactly agreeing ; some inclining to its removal, 
some disposed to temporize. When I saw him, the tumour was 
represented to have increased. My opinion was, that its removal 

F F 2 



436 



might be safelj attempted ; but that it did not appear to me to be 
necessary, since he was in good health, and the tumour gave him 
no pain, nor any other annoyance excepting the deformity it occa- 
sioned. I, however, impressed on him the necessity of watching 
the progress of the tumour ; and, with this view, to take accurate 
measurement of it, which he allowed me to do ; and to attend to 
his general health ; " for," said I, " if the tumour were to increase 
much, and its character remain unaltered, I should alter my opinion, 
and recommend its removal, lest it should acquire a depth and 
extent of connection which might render its removal alike impera- 
tive and dangerous but I added, that, as the tumour had in- 
creased, as he said, it would be satisfactory to me to test the propri- 
ety of my views by a consultation. He accordingly consulted Mr. 
Abernethy, who examined the tumour very accurately, and seemed 
inclined to think that it was the parotid gland ; but I respectfully 
objected that it appeared to me to be too moveable, and that, there- 
fore, it was probably only connected with that gland. On feeling 
it again, Mr. Abernethy assented to this view, and very fully 
agreed in the opinion I had given of the case. I was requested by 
the patient to call occasionally, and watch the tumour. At first, it 
did not increase ; on the contrary, we thought that, if any differ- 
ence, there was a slight diminution. At length, its increase be- 
came very unequivocal, and its adhesion to the subjacent parts 
more close. I now laid before him, as nearly as I could, all the 
circumstances appertaining to the case ; concluding by saying I 
would not press the removal of the tumour ; but, if ever he intended 
to have it removed, that I should advise him not to delay it. An- 
other consultation w^as held ; and this opinion being confirmed, he 
decided that he would have it removed. 

I should mention that this gentleman stated that, until thirty, 
his habits had been rather free as to eating and drinking, but still 
not intemperate, in the ordinary sense of that term ; whilst, for the 
last twenty years, they had been remarkably regular ; his diet w^as 
plain ; and his drinking very moderate — chiefly a glass or two of 
ale after dinner, seldom taking wine, and then only in moderate 
quantity. I should mention that he was stout and somewhat cor- 
pulent ; and indeed the only thing wrong in his habits appeared to 
be a deficiency of exercise : but all his secretions appeared 
healthy ; his pulse was regular ; his tongue perfectly clean ; and 
his appetite natural. A most accurate examination of his abdo- 
men — a measure, in my opinion, which should never be forgotten. 



437 



as preliminary to all severe operations which are not absolutely 
unavoidable — detected not the slightest evidence of disease, the 
corpulency excepted. There was no pain, tenderness, nor fulness, 
nor any other evidence of visceral disease : and it is interesting to 
remark that the region of his liver was most scrupulously exa- 
mined. His mind, too, was very remarkably tranquil, and even 
cheerful. 

I removed the tumour in the presence and with the assistance 
of Mr. Lawrence and Mr. Stanley. Nothing could proceed more 
favourably than did this case, until the only remains of a very 
large wound made in the operation were a spot about as big as a 
sixpence. His friends had called on him, to congratulate him on 
his recovery ; and no one had any idea but that all danger w^as 
over. On calling on him, however, one morning, I found him un- 
well. He told me of a circumstance which had occurred the even- 
ing before, and which had annoyed him considerably — that he had 
had a bad night, and felt cold : his bowels, which had been perfectly 
regular, had not acted as usual. On looking at the wound, I ob- 
served nothing but a small halo of redness around it; and, although 
I said to a friend who joined me on leaving the house, " I hope he 
is not going to have erysipelas," still I had no real apprehension of 
it. How^ever, the next day there was a small district of erysipela- 
tous inflammation. Notwithstanding that everything which was 
thought right was done for him, he became delirious, and died ty- 
phoid about a week from the appearance of the inflammation. 

I could by no means understand this, unless there was some 
visceral disease ; and I was therefore particularly anxious to exa- 
mine his body. This I was allowed to do ; and I must confess 
that, although I felt convinced that I should discover something 
which we had not suspected, yet I was surprised when I found his 
liver to be in such a condition, that I could not assert any part of it 
to be healthy. The whole viscus was of a nutmeg colour ; and, 
both in this respect, and in a peculiar brittleness of structure, was 
exactly that which is frequently observed in those who have been 
addicted to ardent spirits. In short, apart from tubercles, abscess, 
or other depositions, I had seldom seen a liver more markedly or 
more universally unhealthy. 

The following case is also worth notice : 

A man, fifty or sixty years of age, was visited as a patient of 
the Finsbury Dispensary, with an erysipelatous inflammation of the 
knee-joint, attended with oedema of the neighbouring parts; for 



438 



which he had been previously treated by aperients and bleeding, to 
the amount of three pints. His habits were rather intemperate ; his 
employment sedentary; and he drank about four pints of small ale 
daily : moreover, he was subject to gout, and had had a similar at- 
tack some time before, from the prick of a nail. As the foregoing - 
treatment appeared to have produced no benefit, and as he evinced 
disorder of his liver, with imperfect function of his kidney, atten- 
tion was first directed to the liver, and subsequently to the urinary 
organ. At first, this plan was followed by marked improvement, 
but with occasional relapses of his former condition ; which, how- 
ever, again improved under a renewed activity of this plan, com- 
bined with measures directed to his skin. Notwithstanding, he did 
not get well ; on the contrary, the local inflammation at length in- 
creased, and was treated by copious leeching, poultices, and by in- 
cisions, which discharged a large quantity of matter. He, how- 
ever, continued weak ; his debility increased ; and, as this pro- 
gressed, nourishing diet, cordials, and stimulants, as wine and am- 
monia, M^ere employed. His biliary secretion retained its improved 
condition; and the bowels, though sometimes costive, at others 
acting somewhat too freely, were, nevertheless, in the main, kept 
regular. He sank, however ; and, on examination, was found to 
have a thoroughly diseased, nutmeg liver, the spleen being paler 
than natural. 

Here again there was indication of biliary disturbance, indica- 
tion of its yielding readily to measures prescribed for its relief ; 
and yet the liver was thoroughly diseased. I did not see the case ; 
I was in the country at the time ; but we need look no further than 
the liver and the man's habits for an explanation ; although it may 
be questioned whether the loss of three pints of blood had not 
really as much to do with his death as the erysipelas. 

Mr. Leigh's impression, during life, was, that the man fell a 
sacrifice to the bleeding ; and so convinced was he of this, from 
his almost daily observation of the case, that he still thinks that 
the state of the fiver acquired its fatal influence from the further 
debility of natural power, induced by so large a loss of blood in a 
subject so ill adapted to afl"ord it. 

When I came to town, Mr. Leigh told me that he was going to 
examine this man's body ; but I said that, notwithstanding what 
had happened, he would very likely find a diseased liver, as proved 
to be the case. 

These cases have some points of interest. The one to which I 



439 



would chiefly direct your attention is the total absence of any sym- 
ptom of biliary disorder in the first case, and the flattering correction 
of such symptoms in the second. The first patient was not bled for 
the erysipelas ; but he lost a good deal of blood in the operation, 
which, owing to the depth and close connections of the tumour, 
was tedious. The second lost, before his admission into the Dis- 
pensary, three pints of blood. 

To pursue the subject of the circumstances on which erysipelas 
essentially depends, I confess that to me it appears that the true 
way of looking at the subject is to regard erysipelas itself as the 
most unequivocal, whilst it is the most obvious, symptom of disor- 
der of the system ; but, as this presumes the question as settled, it 
may be well to consider a little further the facts on which we coi^- 
clude that erysipelas is to be thus regarded. These facts are, first, 
those which have fallen under my own observation ; and, secondly, 
those which have fallen under that of others, whether of a trite or 
familiar kind, or such as are supposed to have occurred more exclu- 
sively to professional writers or practitioners. 

Now, although not unwilling to test my own experience by that 
of others, still everything that I have written or shall write in this 
' work is to be regarded as deduced, and I trust not incautiously, 
from my own observation. So I speak of the facts which have oc- 
curred to myself; not all the facts in detail, because no man 
forms an opinion as to the nature of a disease on facts so few as to 
be admissible in a w^ork which is not solely devoted to the subject 
to which they relate ; but in a general manner they may be 
stated. 

I never saw erysipelas in which I could not connect it with 
some disordered condition of the general system, or some part of 
the system, or with some chain of circumstances which were obvi- 
ously, and indeed notoriously, of a disordering tendency ; and the 
latter is very important to be remembered. Because, if I knew a 
man's habits to be indolent, intemperate, those of a full feeder, 
without what is usually called intemperance, — or if I knew him to 
have been, in the absence of either or all of these, subjected to 
depressing influences on the nervous system, whether these had 
operated as direct sedatives, as a serious calamity, or the more 
slow, but not less sure, depression consequent on anxiety and ex- 
citement, — I should not think that the erysipelas depended less on 
the peculiar state of his constitution, merely because I could find 
no particular disorder, much less disease, of any particular viscus ; 



440 



nor should I think the nature of the case less certain, though he 
might have a clean tongue and a good appetite (which hy the way 
I never saw). For, although nothing is more true, nor anything 
of more practical importance, than the fact that erysipelas is gene- 
rally more immediately connected with disorder of some one or 
more of the functions of the body, — yet the material element in its 
causation is excitability, with deficient power, be these occasioned 
how they may ; and although visceral disorder, and still more 
visceral disease, are the most certain and the most constant agents in 
the production of this condition, yet they are not to be regarded as 
essential to it. In other words, we know that excitement may be 
occasioned without visceral disorder ; and we know that debility may 
also be produced without any discoverable disorder of that kind ; and 
we know, again, that excitement, if continued, does in all cases pro- 
duce debility ; and we know, also, that the occurrence of debility 
by no means necessarily implies the discontinuation of excitement ; 
on the contrary, we frequently see the excitement increased by it. 

Many causes of a moral nature often demonstrate the foregoing 
propositions ; as grief, fear, anxiety, and the like. But physical 
causes are not less perceptibly influential in the production of the 
phenomena referred to ; — thus, bad air, mwholesome food, vicis- 
situdes of temperature, are equally potent in the production of 
debility ; and generally, perhaps, intermediately through the ex- 
citement they occasion. But, notwithstanding these facts, as bear- 
ing on cases which, superficially regarded, appear sometimes as 
exceptions to a general rule ; still, it is very seldom that we have 
to seek the explanation of erysipelas in any such precursory oc- 
currences alone. 

For the most part, erysipelas is connected with a very tangible 
condition of visceral disorder, and in all cases is accompanied by 
unequivocal proofs of its existence. The fever, the furred tongue, 
the loss of appetite, disordered states of the bowels, though dif- 
ferent in difiierent cases, are always present in a greater or less 
degree in erysipelas : and that the cases in which the more pro- 
minent marks of the disorder of these parts are either simultaneous 
with the occurrence of erysipelas, or perhaps even secondary to its 
early development, are not to be explained othervv^ise than on the 
supposition of a previously disordered condition of various func- 
tions, or of some one function, as the case may be, seems clear ; 
because, whilst various circumstances will produce inflamma- 
tion on the surface, and, as in blistering, somewhat too of an 



441 



erysipelatous character, we cannot certainly produce either ery- 
sipehis or tlie constitutional disturbance bj which it is charac- 
terized, by any accident or artifice whatever. A man may 
have the severest form of erysipelas from the slightest scratch, or 
he may have the most severe and complicated injury without any 
erysipelas whatever. So that we can in no way connect either the 
general or local character of the disease with the local or general 
circumstances in the relation of direct cause and effect, in the prac- 
tical or philosophical sense of the word ; but when we look to 
erj^sipelas more carefully, we find it connected in many cases with 
more particular or more permanent disorder of particular organs; 
and of these I know no one by which this is more frequently ex- 
emplified than the liver. 

The frequent coexistence of disorder of the liver, including 
congestion of that organ, is an important point in the consideration 
of erysipelas. I have mentioned Dessault's record of the circum- 
stance. We often see the disorder very prominent during life ; 
secondly, after death, in changes of structure, of which the sym- 
ptoms during life afforded little or no indication ; and again, we 
infer it, though with less certainty, of course, from the fact that 
some of our most potent remedies in erysipelas, though not ad- 
ministered with that intention, have, amongst other properties, these 
two, — viz. a power of producing very marked effects on the liver, 
and also considerable influence in equalizing the circulation. This 
applies to other remedies ; but the one to which I now refer is mer- 
cury, and especially calomel. 

We must not, however, infer that there is avxj pendkir connec- 
tion between disorder of the liver and erysipelas ; for even if 
erysipelas be more constantly connected with disordered liver than 
any other organ, yet this may merely be explicable on the ground 
that the liver is more exposed to, or more affected by, those habits 
of Kving which produce other derangements favorable to erysipela- 
tous inflammation. A gorged liver is constantly pouring a very large 
column of blood almost directly into the heart ; this is certain ; and it 
it is equally so that this may produce excitement of the organ, or add 
to that which it may derive from other sources ; and which excite- 
ment is an ever-failing concomitant of erysipelas. These circum- 
stances may indeed render the liver a frequent seat of disturbance : 
but we must not infer that this is invariable ; for nothing, I think, is 
more clear, than that the disordered condition in other instances 
depends on other organs ; and, in some instances, on influences of 



442 



a moral kind, which appear to have acted primarily on the ner- 
vous system as a whole. 

A question has been mooted, how far erysipelas occurs in other 
parts than those mentioned at or near the surface of the body ; 
whether, in fact, it occurs in parts situated in the interior of the 
body. If by this is meant an inflammation, presenting exactly the 
same appearances and exactly the same results as we observe 
when it takes place on the skin, or the structures immediately 
beneath it, I do not see that we have any facts by which we can 
demonstrate such similarity ; but if w^e regard the question as re- 
ferring to the presence of the same general characters, and espe- 
cially to that departure, which erysipelas on the surface and certain 
inflammations in the interior of the body alike present, from what 
we have reason to regard as healthy inflammation, — 'why then, in- 
deed, I think the similarity very striking. 

The rapid diffusion of inflammation in erysipelas is exactly 
what happens in inflammation of the peritonaeum, the pleura, or 
the membranes of the brain. In both, in many cases, we see the 
same failure of that adhesion which circumscribes healthy inflam- 
mation ; and in both we see abortive attempts at it. In erysipelas, 
in the thickening and consolidation of many parts of the cellular 
tissue, and in membranous inflammations, in that irregular inter- 
mixture of the adhesive process with the other products of inflam- 
matory action, which it is found practically not to have circum- 
scribed. Mr. Lawrence seems, 1 think, to doubt this analogy in 
page 19 of the very excellent paper already quoted. In speaking 
of erysipelas occurring in internal membranes, &c., Mr. Lawrence 
observes, The proof of such an opinion would consist in shew- 
ing that the same peculiarities which distinguish erysipelas from 
other inflammations of the skin, are found in certain inflammations 
of the parts just enumerated*, and that such aflections may hence 
be distinguished from ordinary inflammation of the same organs. 
No attempt of this kind has been made ; on the contrary, nothing 
can be more vague or unsatisfactory than the arguments by which 
Frank attempts to support his opinion. Since the distinguishing 
characters of erysipelas are clearly referrible to the peculiarities of 
the cutaneous and cellular structures in which it occurs, we could 



* " Conjunctiva, mouth, fauces, of the respiratory and alimentary mucous 
surfaces, of the serous membranes, in the head, chest, and abdomen, and of the 
brain, abdominal and thoracic viscera." 



443 



not expect to meet with the same affection in parts so differently 
organized as serous membranes and the viscera." In the first 
place, the existence of erysipelatous inflammation in internal 
organs is one thing ; the power of distinguishing it from other in- 
flammations is another. With regard to the observation of Frank, 
I cannot altogether agree with Mr. Lawrence ; but, that the reader 
may judge of this, I have copied the quotation*. 

I have already observed, of the local characters in many cases 
of membranous inflammation, that whether we compare those 
commonly observed with those of more healthy character, or with 
erysipelas, they are at least allied to erysipelas quite as much as they 
are to common phlegmonous inflammation. Again, the distingmshiny 
characters of what we may agree to call erysipelas, may be well 
enough referrible to the cutaneous and subcutaneous tissues ; but it 
does not follow^ that though the physical characters of the inflam- 
mation be different, its nature must necessarily be so. Inflamma- 
tion of the cornea and iris present very different characters, and 
very possibly resulting from the difference of structure ; but they 
are in many, and indeed most cases, as to their essential nature, 
the same. In fact, as has been already observed when treating of 



* " Internum quoque et ad viscerum superficiem residens haberi erysipelas, a ve- 
teribus creditum, a recentioribus vero in dubiiim vocatum est. Novimus tamen, 
non modo in viventibus encepbalitidem, otitidera, peripneuraoniam, enteritidem, 
singulasque inflammationum species, comparente ad externara corporis superficiem 
erysipelate protinus disparisse ; hoc ipsum vero ab externis genitalibus, sine inter- 
ruptione phlogosis, per vaginam ad uterum ; a facie ad fauces, asperam arteriam, 
pulmones, cseterasque ad partes internas manifeste peneti'asse ; sed etiam in cada- 
veribus ad urethram, vesicam, vaginam, uterum, ovaria, intestina, ventriculum, 
hepar ; in pectore ad pleuram, bronchia, pericardium, cor ipsum ac vasa raajora ; 
in calvaria ad meninges, ad cerebrum ipsum, frequentius certe erysipelatosa, quam 
phlegmonosa occurrit inflammatio. Ex mammarum schirro, dexterrima licet 
manu, per cultrum ablato, erysipelas in singulis fere corporis externi partibus, ac 
tandem lethalis peripneumonia successit : post quam pulmones undique correptos 
erysipelate, ex flammeo rubentes, nec duros, sed copioso sero innatantcs conspexi- 
mus ; ac pars plurima certe peripneumoniarum malignarum cum erysipelate pul- 
monum incedit ; nec durus, nec cocto similis hepati ac ponderosus in cadaveribus 
pulmo in illis detegitur. Nullum ergo de interni erysipelatis frequentia- dubium 
superesse potest, licet signa charcteristica, quse banc potius, quam phlegmonosam 
affectionem ad viscera indicent : nisi ab externo et retropresso erysipelate, aut a 
manifesta interni hujus raali ad externam partem non interrupta continuatione, ex 
epidemica per sectiones pathologicas confirmata morbi ndole, ex cachectica sub- 
jecti constitutione ac prona in erysipelas natura, ac demum ex causis inflamma- 
tioni verse parum faventibus, desumatur ; adduci non queant." — J. P. Frank, De 
Curand. Homin. Morbis, lib. iii, p. 28. 



iuiiaiiiiDation, the process is modified very much, cceteris paribus, by 
the structure in which it occurs, as regards its appearances and its 
results ; but we do not think it necessary to suppose it different in 
its nature on account of such circumstances. However, after all, 
I would rather be understood as contending;, that many cases of in- - 
tlammation of the membranes of the chest and abdomen are not 
demonstrably different in their nature from erysipelas, than that 
they are necessarily the same. What is more material, is, that they 
are both alike aberrations from what we have every reason to re- 
gard as the healthy manifestation of inflammation in the parts 
respectively ; and that the point in which they constantly resemble 
each other, is that rapid diffusion of inflammatory action which is so 
characteristic of erysipelas. 

Another question which has given rise to much discussion at 
different periods, is the contagious nature of erysipelas ; but, narrow^ 
as tliis question may at first sight appear, you would very soon 
find that a proper consideration of it would immediately involve us 
in the question of the laws of contagion generally — a question 
which I have no present opportunity of considering, but which 
requires the aid of inductive philosophy as much as any with 
w^hich I am acquainted. I can here only offer a few brief remarks. 
The facts in regard to erysipelas, and to all diseases whatever 
which appear to be communicable from one person to another, 
whether by contagion (in the sense of contact or contiguity) or by 
infection, shew this in common, — that neither contact, contiguity, 
nor breathing the atmosphere of the same apartment, nor even 
inoculation, will invariahly produce the disease in another person. 
That also all the diseases will occur, in certain cases, without any 
of these circumstances, so far as it is possible to perceive ; and that 
the first case must have so occurred, is evident, as regards any com- 
munication from the human subject. That, therefore, some other 
link must connect the chain of phenomena, — in other words, that 
there is some condition or other, be this what it may, which is 
necessary in order that exposure to contngion may produce disease 
in the person so exposed ; and we know that many states of 
the system point very decidedlj- to the probable nature of this 
condition. 

All the facts which I have adverted to, are true in regard to 
all diseases which have been regarded as contagious, although they 
apply with very different force to different varieties. The necessity 
of some condition of the body being an essential link in the chain 



445 



of commnnication is especially striking in diseases which, if they 
have once occurred, can hardly be produced a second time, such 
as small-pox ; Init even this is not without exception. In some 
diseases also, only a few persons are affected in a manner justifying 
the idea of contagion or infection; whilst in scarcely any do we 
find the majority of those exposed affected. In those cases in 
which large numbers of persons in towns or districts become af- 
fected by a similar disease, the circumstances are generally alone 
explicable by the supposition of a general influence, such as certain 
states of atmosphere ; by supposing that the disease is epidemic, 
as we term it. But here again we see the same link required ; 
since, if there be not some condition of the body necessary, how is 
it that so many escape, — I mean of those in whom no differences 
as to exposure are observable. 

I have just said enough to shew you how large a field of en- 
quiry the question of contagion opens. For my own part, it seems 
to me that, in most, perhaps all, diseases;, there is something emanat- 
ing from the body, either by the skin, or lungs, separately or in con- 
junction, w^hicli is either injurious in itself, or becomes so when mixed 
with the atmosphere, or both ; and that, subject to that separation of 
its particles which appears as a la^v in regard to gaseous or aeriform 
products, it will affect the air, as it is confined to a small quantity, 
or diluted by free communication with the general atmosphere : 
that these exhalations are more injurious in some diseases than 
others ; and in some they are so highly pernicious as to affect a 
great number of people with unusual certainty, when we call them 
poisons. That the power of withstanding or combating these in- 
jurious actions is different in different persons, let the cause be 
what it may ; and that where the powers are inadequate to these 
by some affection of the ordinary functions, then an action is set up 
on purpose to localize the disease, and to bring it to the surface of 
the body ; and that this fails or succeeds with various degrees of 
exertion, just according to the real powers of the oeconomy. That 
this is, in truth, catching the disease. That, in this effort, the 
diseased manifestations in the infected person are the same as 
in the individual from wdiom the disease may be said to have 
been caught ; but that this may not be in all cases necessary : in 
other words, that exposure to a particular form of disease may not 
necessarily oblige, in a differently conditioned individual, the same 
diseased manifestations for its rejection, but that his constitution 
may do it better in some other way, or by excitement of some se- 



446 



cretion, and so on. And that all diseases of an infectious nature 
occur both from causes ^'hich we call epidemic, and also from 
contagion ; but that both one and the other alike require, as the 
connecting link in their communication from one body to another, 
some particular condition in the body to which the disease is com- 
municated. 

I maj here state a fact which occurred lately under mj own 
cognizance. Five people living in a house where the drain had 
become obstructed, and had given rise to noxious efflu^na, were 
affected in succession as follows : An elderly man had erysipelas and 
inflamed absorbents : next, an elderly woman had continued fever, 
with flushing of the face, suffused eyes, and deranged bowels : then 
a boy was seized by sore throat and inflammation of the tonsils ; 
and, lastly, a young woman was affected by an acute attack of in- 
flamed absorbents and erysipelas of the right arm. So far as these 
facts go, they are very instructive ; but I cannot enlarge at present 
on this vast subject. 

Practically, we do not find cases of erysipelas appearing as the 
result of epidemic causes or contagious influences, so commonly 
as some other diseases ; but that the disease does occur occasionally 
under both of these kinds of influence, is, I think, with the condi- 
tion of which I have spoken, indisputable. The practical inference 
from this applies also to all diseases ; — viz. that the apartment 
should be kept at a moderate temperature and w'ell ventilated ; 
and that, as in all diseases the body is either throwing off, 
or attempting to throw off, something injurious to it, it is not 
likely to be otherwise than unwholesome to other bodies ; that, 
therefore, sick rooms should be avoided generally by those whose 
professional or social duties do not lead them to visit such places ; and 
that this caution applies with greater force to some diseases than 
others, and to people who are either not in fair health, or who are 
unaccustomed to such exposure. 

There are two other diseases on which I would remark, in con- 
nection with erysipelas ; because I think there can be no doubt but 
that they are essentiahy the same in their nature. The one is in- 
flammation of th"^ absorbents, which often occurs in connection 
with erysipelas ; and the other, that case which we observe as the 
result of wounds received m dissection. With regard to inflam- 
mation of the absorbents, I do not expect that the identity of its 
nature with erysipelas will, in a general sense, be disputed. iNIen 
are divided in opinion in regard to these cases ; some considering 



447 



them the result of absorption of poisonous matter ; others regard- 
ing them as ordinary cases of erysipelas, or at least as occurring 
from a wound received in a disordered state of bod;-, to which dis- 
ordered state of body the unpleasant and sometimes fatal conse- 
quences are attributable. Now, whilst I must impress on you that 
I am far from denjnng the possibility of poisonous matter being 
absorbed in some cases, I must unhesitatingly avow my disbelief 
in its general, or even other than very rare, occurrence. 

In relation to wounds in dissection, we have the following facts : 
— that many hundred indi^iduals are occupied, during the winter 
months, nay from the middle of October to the end of April, in 
London alone, in dissection : that it is certain that the majority, and 
presumable that the whole, of these either scratch or cut the finger 
once during the season, either in the process of dissection or from 
other causes : that, averagely, scarcely one in fifty becomes affected 
by that inflammation and febrile excitement which sometimes fol- 
low on the infliction of these wounds. That they live in a crowded 
city ; that their employment invariably exposes them to the daily 
influence of an atmosphere tainted by animal matter in various 
states of decomposition ; that most of them come from the country ; 
that, in many cases, their habits of study or inclination lead to 
keeping late hours, and in other respects are more or less irregular. 
That, practically, many do suffer in their general health from the 
influence of such causes ; and that very few indeed fail to evince, 
in the spring, in their feelings and even in their appearance, the 
eff"ect of an anatomical season spent in a large and crowded city. 
That although, occasionally, facts seem to point to the influence 
exerted by particular bodies, or to bodies dying of particular dis- 
eases, as having some connection with the production of the in- 
flammation consequent on wounds in dissection, — yet that the 
contrary instances are so numerous, that, practically, no such con- 
nection can be established. Neither can we attribute anything 
safely to particular states of decomposition ; since some of the 
worst cases have occurred from bodies which were perfectly fresb, 
and in which no decomposition appeared to have begun. 

With regard to the last point, it would seem that butchers and 
cooks often experience effects similar to those which occasionally 
follow wounds in dissection. Whereas, though they are engaged 
in cutting animal matter, yet it is not commonly in a state of de- 
composition. It should be remembered, also, that the employment 
of both butchers and cooks involves many things of an injurious 



448 



tendency ; and that they are both commonly found to be unfa- 
vourably conditioned when they become the subjects of accident 
or disease. We know, also, that sometimes the wound is a punc- 
ture by a sharp instrument ; at others, a cut ; at others, a graze, as 
by rough portions of bone, &c. ; and, in a few cases, there has been 
reason to doubt whether any wound had been inflicted. That the 
symptoms are pain, swelling, redness of the limb, abscesses, lines 
representing inflamed absorbents, suppuration, and various febrile 
affections of greater or less intensity ; and, in short, in various de- 
grees of intensity or combination, all those phenomena which we 
remark as characterizing erysipelas, and inflammation occurring 
without any connection with any of the employments I have men- 
tioned. 

The difficulty, then, at which we have already arrived in en- 
deavouring to refer the occasional consequences of wounds in 
dissection to the absorption of particular poisons is this — that 
erysipelas presents us with a similar, and in many cases with an 
identical, series of phenomena, where we cannot, with any reason- 
able probability, suppose the agency of such poison : for, not only 
does erysipelas occur without any wound at all, but also after 
wounds of all kinds — clean cuts, scratches with wood, iron, straw, 
clean needles, needles never before used*, and, in short, under a 
variety of circumstances in which we must regard the supposition 
of any poison not only purely gratuitous, but in the highest degree 
improbable. The universally admitted general connection of dis- 
ordered health in the two classes of cases is also a very important 
similarity. 

Now, if we direct our attention to the phenomena resulting 
from the best established specimens of morbific poison with which 
we are acquainted, we shall find the analogy presented with the 
cases resulting from wounds in dissection as imperfect as that pre- 
sented between such cases and erysipelas is striking. The first 
thing to be observed in the consequences of the insertion of poi- 
sonous matter is the striking uniformity of its results. The stings 
of bees, the bites of serpents and of rabid animals, inoculation of 
small-pox, all produce results of striking uniformity of character. 
Many of these scarcely ever fail ; and none of them, except in very 
rare instances. Their effects, it is true, vary extremely in vio- 
lence ; but scarely ever in kind. The exceptions are so rare as to 



* Cruikshanks' Anatomy of the Absorbent Vessels, p. 43. 



449 



be incalculable ; whilst, in regard to wounds received in dissection, 
the case is the very converse of all this — that is to saj, that for 
one person who becomes alfected, at least fifty escape : we have 
no parallel to this, nor even any approximation - to it, in regard to 
any poison with which we are acquainted. 

Neither is the difficulty of any attempt to refer the occasional 
effects of such wounds as are received in dissection to the absorp- 
tion of poisonous matter, diminished by restricting the notion either 
to those cases in which the appearance of red lines, indicative of 
inflamed absorbents, is the primary symptom ; for, whilst these red 
lines are of constant occurrence in cases where we can by no 
means assume the presence of any poison, so, on the contrary, 
they are frequently absent where we can infer the presence of a 
poisonous principle with the greatest probability. 

In Cruickshanks' Anatomy of the Absorbing Vessels, p. 73, 
it is said, that " Mr. Hunter saw a case in which the skin, being 
pricked by a needle which had never been used before, or touched 
any infecting or irritating substance, occasioned the lymphatics 
(absorbents) of the arm to inflame and shew themselves in the 
form of red lines running towards the armpit. In consequence of 
this, some one of the glands was also inflamed and swelled ; the 
patient had rigors and sickness ; and all this in the space of a few 
minutes : he adds, I have seen also similar cases.'' Examples, 
however, of a similar kind are of daily occurrence ; — I mean, 
where a wound having been received under circumstances by no 
means allowing of the supposition of any poison, the irritation of 
the absorbents is indicated in the manner here alluded to — red 
lines running up the arm, and irritation in the glands to which they 
lead. 

Then again, the glands may inflame, under such circumstances, 
without any red lines indicating the irritation of the absorbents lead- 
ing to them : and, in cases where the existence of some peculiar or 
poisonous principle is best established, such red lines are by no 
means constant, nor, in relation to the number of cases, are they 
even to be regarded as frequent occurrences ; as in small-pox, cow- 
pox, and syphilis. Again, in cancer, irritation is often set up in the 
glands in the neighbourhood of the disease ; but it by no means fol- 
lows that there be any red lines, or that the actions in the gland 
shall be, in everij case, cancerous. 

But, perhaps, after all, the most impression is made by the rela- 
tion of cases which appear to me to demonstrate the fact, that no 

G G 



450 



peculiar principle or poison is necessary to the phenomena observ- 
able ; and that the existence of such a poison in ordinary, or 
indeed in other than very rare cases, cannot be inferred in the 
affections resulting from dissection, unless we determine to refer all 
the cases in which the phenomena occur to the agency of some _ 
poisonous principle, which involves suppositions to the last degree 
gratuitous : but I must state the facts generally, referring you to the 
respective works for a perusal of the cases whence they are drawn. 

I had intended to make a copious analysis of Dr. Butter's valu- 
able cases of irritative fever, and of Mr. Lawrence's paper on ery- 
sipelas, in order, with other cases, to put the whole subject in a 
point of view equally illustrative of both classes of cases ; but I found 
that the space required would have been quite sufficient for a sepa- 
rate treatise, and which I think would be highly useful. I am re- 
luctantly obliged to content myself with a few passing remarks. 

Dr. Butter published a work on irritative fever, describing a 
disease which had occurred in the Plymouth Dock Yard in 1824 ; 
in which we perceive that it is impossible to regard the cases in any 
other light than inflammation of the absorbents, or erysipelas; 
separately, or in combination. The wounds received were from 
nails, glass, or bits of wood, slight grazes, and in short all those 
which so notoriously are followed, occasionally, by these affections. 
The book is very instructive in relation to these matters ; and it 
shews how impossible it is to distinguish such cases from those 
ordinarily occurring from wounds in dissection, or many cases of 
erysipelas. It contained, also, what appears to me the clearest 
evidence that blood-letting, as a general remedy, is commonly un- 
necessary, and often dangerous. We find evidence here, that 
scarcely any patient largely bled recovered. Of twenty patients, 
nineteen died ; and thirteen of them had been blooded. In three 
cases, also, recorded by Dr. Colles, but which resulted from wounds 
in dissection, one was bled (Professor Dease), and died ; the two 
others recovered, but they were not bled. Dr. Bell, of Plymouth, 
who punctured his finger by a needle, used in sewmig up a body, 
was largely bled, and he died also. 

Dr. Butter, in relation to wounds in dissection, gives two 
letters, the one from Sir Astley Cooper, the other from Mr. x-\ber- 
nethy ; but they both contain evidence of the opinion of these dis- 
tinguished surgeons being opposed to blood-letting, as applied to the 
consequences of wounds received in dissection. Sir Astley Cooper 
mentions local bleeding, but does not even hint at general blood- 



451 



letting. They both, m a general sense, oppose the opinion of the 
absorption of morbific poison : whilst again, the one positively 
(Mr. Abernethy), the other inferentially, recognize the coexistence 
of general disorder. Sir Astley Cooper, speaking of his own case, 
says, " I have only once severely suffered from a wound in dissec- 
tion, and then it was the result of an injury on my thumb, in dis- 
secting a person who had been executed the day before. The sym- 
ptoms were pain in the injured part, swelling, inflamed absorbents, 
enlarged absorbent glands in the axilla, irritative fever, a continued 
sore throat, and an inflammation, first on my left, and, after a few 
days, in my right knee. Medical means relieved me, but did not 
cure me; but / recovered ongoing into the country ^ Mr. Aber- 
nethy says, " I do not think that there is reason to believe that, in 
general, the animal matter, which may be on the instrument inflict- 
ing the wound, acts as a morbific poison;" and, as I before said, 
he thinks blood-letting improper. He says, also, " I have known 
persons die after such illness ;" that is, wounds, followed by inflam- 
mation of absorbents, &c. generally, " apparently from affections of 
the bowels, brain, and lungs." He considers that the cases of ery- 
sipelas and irritative fever generally owe their peculiarities to the 
disordered health of the patient, I w^ill here observe, that I attach 
great importance to all points in which two such men as Mr. 
Abernethy and Sir Astley Cooper agree, and especially one where 
they must have had such almost unparalleled experience, as in regard 
to that class of cases which result from wounds in dissection. 
There is weight in their coincident opinion, which, highly as I re- 
spect both authorities, I attach to neither separately ; for reasons 
which, though equally honourable to both, regard the somewhat 
different mode of enquiry usually pursued by these gentlemen. 

In my own case, the body was perfectly fresh, and the first sym- 
ptoms I experienced were pain in the head and shoulder, and, sub- 
sequently, abscesses, but no erysipelas. I was very ill, and suffered 
a great deal of pain ; but got well, although I was much excited by- 
other circumstances at the time. I was not bled. 1 am sure that 
I have wounded myself in dissecting and examining bodies very 
frequently, but never suffered any ill consequence but on that one 
occasion. Constitutionally, the worst symptom I had was pain in 
the head ; as regards suffering, pain in the shoulder. 

The mode you should adopt in judging of the essential nature 
of " wounds received in dissection," inflammatian of the absorbentSj 

G G 2 



452 



and erysipelas, is simplj to place the cases related, as examples of 
either, side by side, when their identity will be sufficiently manifest. 
This, Dr. Butter's book will almost, alone, enable you to do ; but 
it will be still more easy if you take with it any work written ex- 
pressly on erysipelas; as Mr. Lawrence's paper in the Medico-Chi- - 
rurgical Transactions, for example. 

I am the more anxious to invite the attention of the profession 
to such a view of the subject, because, in connecting the treatment 
of such cases with that of the proper treatment of erysipelas, I 
believe that many lives will hereafter be saved ; and because I find 
that the great space occupied by a full discussion of this part of the 
subject is inadmissible within the limits of this work. Such an en- 
quiry would, also, I believe, furnish the student with the best preven- 
tive, in the impressive conviction which it would convey, that such 
security is most certainly to be found — in daily exercise, in habitual 
temperance, and careful regulation of the functions of the body ; 
and in disabusing his mind from that unnecessary degree of alann, 
which, I am convinced, often exerts a most pernicious influence in 
such cases. 

I may now, then, proceed to consider the treatment of ery- 
sipelas ; and here, if we consult authorities, we shaU meet with a 
difference of opinion, which is at first very perplexing, but which, 
careiully considered, becomes less embarrassing ; and which, tested 
by observation of erysipelas as it occurs in natnre, points to the 
right treatment, in a manner which, whilst it doubtless leaves still 
much to the discretion of the practitioner in individual cases, shews 
very clearly the principles on which, in all cases, such treatment 
ought to proceed. The chief difficulty which occurs relates to 
blood-letting, involving the following questions : — when we should 
employ it ? how we should employ it ? or, whether we should em- 
ploy it at all ? 

One point on which all writers agree, is this — that the treatment 
on which they place their chief reliance involves an agency which 
refers to the body in general, and belongs, in common phraseology, 
to what is termed the constitutional treatment ; for it is evident that 
bleeding, purging, emetics, &c. must act by an influence directed 
either immediately or mediately, through some organ, to the general 
state of the body. We therefore (supposing that the observation 
of natnre presents nothing to the contrary) shall be most safe, as to 
any reliance on authority, in concluding that we must look with 



453 



confidence only to sucli measures whicli, be their application local 
or not, act by an influence affecting the whole constitution ; as you 
will presently see. It is necessary, also, if the views which I have 
given you of inflammation generally be correct, that the treatment 
should be in harmony with them ; whilst the very difference of 
opinion of different writers, in regard to different parts of the treat- 
ment, point, as well as those in which they coincide, to two facts : 
first, that erysipelas is connected with some disorder of the system 
generally ; and, secondly, that this disorder may proceed from 
different causes in different cases. 

The evidence deducible from all writers shews also a general 
confidence in measures whicli tend to empty the alimentary canal, 
and to improve the secretions of the chylopoietic viscera. A gene- 
ral admission of the importance of measures directed to the skin is 
also demonstrable. Again, the evidence gathered from such 
sources shews^ in regard to erysipelas, the universal admission of 
high excitement with subdued power, — excitement in the state of 
the heart and arteries, subdued power in the sloughing, and invari- 
able departure of one kind or other from the processes of healthy 
inflammation. 

It is to be feared that much of the difference of opinion, ob- 
servable in the subject of treatment, may have resulted from differ- 
ent men having referred to different periods of a case ; for nothing 
is more certain than that a treatment, proper at one period, may be 
unnecessary or even injurious at another — a distinction of great 
practical importance ; since cases are in fact presented to us at all 
periods of their progress : some when the greatest advocate for 
bleeding would, as well as those most opposed to it, allow that 
it was unnecessary ; others, who oppose stimulants or bark, &c. 
would as readily use it as Dr. Wells, or Fordjce, or any others 
who have written in its recommendation. All slight cases, or even 
those which ultimately prove severe, at their earliest commence- 
ment are examples of the former. Take the following as a glaring 
example of the latter : — 1 was sent for to a man who had received 
a graze on his shin from an iron grating ; erysipelas had followed ; 
and, when I saw him, nearly the whole integuments of the leg and 
thigh had sloughed (fascia and all) up to the trunk ; and, on the 
lower part of the trunk, there was still a district of erysipelatous 
inflammation. I found him taking wdne, bark, and ammonia, by 
the prescription of two gentlemen who had attended him previ- 
ously to his sending to the Dispensary. His pulse was freq^ueiit ; 



454 



tongue moist, but very much coated with a brown fur ; and he was, 
as I thought, m the last stage of exhaustion. Nevertheless, I took 
off his wine, and substituted porter, which he happened to prefer. 
I struck off the ammonia, but allowed the bark to be continued. 
I had his bowels cleared bj small doses of aperients and an injec- 
tion ; and I allowed him small quantities of beef-tea, with toasted 
bread, and a little boiled mutton, should he feel inclination for it, 
but not otherwise. 

Any one would have agreed in endeavouring to support this 
man ; and no one would have thought of bleeding him : yet, in 
supporting him, there were several modes of proceeding. I should 
have been as glad as any one that he could have taken wine ; but 
I forbade it simply because I knew^ it must excite him ; and I saw 
that it was not producing strength ; and therefore I thought him 
better without it, and so of the ammonia. Of the exciting pro- 
perty of his bark I was not so certain ; therefore 1 allowed it to be 
continued ; and I thought porter might strengthen him when wine 
did not ; at all events I felt the probability that it would not stimu- 
late him so much. Before he had continued this plan forty-eight 
hours, he began to fancy some boiled mutton, which he was allowed 
to take ; and when, on the following day, I saw that his tongue had 
become cleaner, I declared my opinion to the pupils that with care 
he would recover ; and so he did, although his recovery was very 
slow ; as well it might be, with so much repair necessary. I need 
not go further into that case, as I merely mention it in illustration 
of the difference of treatment which may be required according 
to the circumstances under which you first see your patient, 

I need not specify particularly the treatment necessary in the 
various kinds of erysipelas ; there is no essential difference in the 
nature of the disease ; and the treatment will obviously appear 
with its appropriate modifications from that of m-ore severe exam- 
ples, or from the relation of a few cases : those cases, therefore, to 
which my observations are in a general sense directed, are what 
are called cases of phlegmonoid erysipelas, in which, whether oc- 
curring from accidental injuries or otherwise, the inflammation 
creeps up a limb with greater or less rapidity ; and which, if it be 
not subdued, is followed by extensive sloughing and unhealthy sup- 
puration in the skin, cellular tissue, or fascia, or all these parts, and 
which may or may not prove fatal. 

The foundation of the treatment proper in erysipelas, if we are 
to improve that present ministering to symptoms which character- 



455 



izes the general treatment of inflammatory affections, is the sus- 
tained impression of general disorder, or disorder of particular 
organs, as its cause ; and also that, as an evidence of this general 
fact, the erysipelas itself is conclusive. 

I will at once cite a few cases illustrative of the disease in its 
light as well as its severer form ; and also of affection of the ab- 
sorbent vessels. 

SLIGHT CASE OF PHLEGMONOID ERYSIPELAS, FOLLOWING A 
PUNCTURE FROM A PIECE OF CLOVER-HAY. 

Joseph Chance, set. fortj-two, a builder's labourer, applied with 
phlegmon oid erysipelatous inflammation of the thumb and hand, 
consequent on having, in unloading a cart of clover-hay, punctured 
liis thumb with a piece of clover. He has pain, running up the 
inside of his arm, and a swollen gland in the armpit. His tongue 
is dry and tremulous ; pulse frequent ; bowels costive : he was 
ordered to avoid all kinds of grease, fat, or butter, in diet, and to 
eat no meat : he was ordered to take the compound calomel pill 
every other night ; and a saline aperient, with one -eighth of a grain 
of tartrate of antimony, every six hours. He did not apply again 
until the 23rd; and then came himself. The swelling in the 
axilla was less ; tongue moist; says he " feels in better health ;" 
no pain ; now there seems some fluctuation in the thumb ; but the 
inflammation is fast subsiding. He came again on the 29th : in- 
flammation nearly gone ; altogether better ; tongue moist and nearly 
clean. — February 2. He complains that he is not so well; his 
bowels costive. There being still some sensation of fluctuation in 
the thumb, it was opened, and a small quantity of matter dis- 
charged. His saline aperient to be strengthened ; and one-sixth of 
a grain of tartrate of antimony taken with each dose. — February 
5. Bowels open ; pain subsided ; in all respects better. No further 
treatment necessarj^ At the next visit he was discharged well. 

PHLEGMONOID ERYSIPELAS AND INFLAMED ABSORBENTS, 
FOLLOWING A WOUND RECEIVED BY A FALL ON SOME 
GRAVEL. 

Edward Hardy, set. forty, reports himself temperate, but much 
exposed to all weathers, in his occupation, that of a hawker of 
fire-wood.— June 24. He says that, a few days since, he fell down 



456 



on some gravel, wliicli slightly injured his hand. His tongue was 
white ; pulse quick, but feeble ; bowels open. He was discharged 
a fortnight ago from an hospital, where he had been on account of 
a " rheumatic fever." His nervous system seems very excitable ; 
and says he is easily " flurried." His hand is very much swollen, 
and of a dusky red ; a portion of which redness extends up the 
inside of the arm to the axilla, where there is a swollen gland. 
Suppuration has already taken place in the hand, which is still dis- 
charging. He was ordered low diet ; no meat ; poultice ; leeches; 
and rest ; and a saline aperient, with one-eighth of a grain of tar- 
trate of antimony. — June 28. His tongue still white, but moist ; 
bowels purged: pulse 110, sharp and frequent; inflammation of 
the arm more vivid : has eaten meat, notwithstanding the injunc- 
tions to the contrary ; and his appetite is defective. To omit his 
mixture for a day ; to repeat the leeches and poultice ; to lay his 
arm on a pillow, and not to come out. — 29th. Much the same. 
— July 1 . In all respects better ; inflammation nearly subsided ; 
says he has taken nothing but gruel ; and has been otherwise strictly 
attentive to the directions given him. Discharged well on the 11th. 



CASE \YITHOUT ANY PREVIOUS LOCAL INJURY. 



Thomas Wilcox, eet. forty, residing in Featherstone Street, 
St. Luke's, employed in an iron foundry, first found his hand tender 
on the 8th of February, not having received any wound or other 
injury thereon ; the next day had pain shooting up his arm, and 
swelling in the axilla. His bowels are very confined, and he con- 
fesses that he is accustomed to drink spirits freely. The whole 
hand is now swollen ; there is pain extending up the arm to the 
axilla : he has been, however, trying to work a few days since the 
first occurrence of the pain in the hand. Tongue white, pulse 
frequent and pretty strong, particularly in the aifected arm ; he is 
ordered jalap gr. viii, and calomel gr. i, every three hours until his 
bowels are opened, and a pill at bed- time, containing calomel and 
ipecacuanha, two grains of each ; a poultice of bread and water to 
the part; gruel diet, and rest. This was on the loth and 16th ; 
bowels open three times ; arm easier ; there seems an obscure fluc- 
tuation in the hand ; made a moderate incision and let out a very 
small quantity of matter, about a teaspoonful only ; ordered a saline 
aperient with one-eighth of a grain of tartrate of antimony, and 



457 



leeeches, which, howevei^ he is not to apply unless his arm gets 
worse.— 20th. Is worse, notwithstanding that he has put on the 
leeches : hand much inflamed ; pain and tenderness at the arm 
increased, and threatening extension of suppuration of the hand. 
Notwithstanding the injunctions given him as to diet, he now says 
that he has been eating veal and bacon. Repeat sixteen leeches ; 
poultice far too small, this to be properly applied ; strong injunc- 
tions to take nothing but gruel. — 2]st. Is better; has obeyed di- 
rections as to diet ; leeches applied ; arm a great deal easier ; 
bow^els open, thrice yesterday; no pain in the axilla; pulse ninety- 
two ; ordered to continue the saline aperient without antimony, but 
to take compound calomel pill every night. Under this plan the 
pulse became steady and regular at eighty. Hand discharges very 
freely ; swelling subsided. He was very shortly after discharged. 



CASE OF IRRITATION OF THE ABSORBENTS. 

Lucy Doren, set. sixty- two, applied July 8th. Has a collection 
of matter at the root of the nail of the middle finger, consequent 
on working with a thimble which pressed on an agnail. There is 
pain all up the arm ; this is very violent, and prevents her from 
getting any rest. There are two swollen glands in the axilla ; 
tongue dry and white; bowels costive ; has taken salts, but they 
have not operated. An incision is made through the skin and a 
small vesicle, from which a small quantity of moderately healthy- 
looking matter and a little serum is discharged. A linseed -meal 
poultice to the part, and a saline aperient with one-eighth of a grain 
of tartrate of antimony every six hours. Did not come again for 
a week, when the finger was nearly well ; wished to give up her 
letter, but I advised her to keep it a few days longer ; tongue 
nearly healthy ; she continued a few days and was discharged. 



CASE OF SEVERE PHLEGMONOID ERYSIPELAS FROM A GRAZED 
WOUND OF THE LEG. 

A gentleman, set. thirty- eight, very stout and plethoric, and 
accustomed to fall living, desired my attendance on account of 
active phlegmon oid erysipelas of the leg. A few days since he 
had grazed his leg in getting out of a cabriolet, and had sent for a 



458 



medical man, \y1io had applied some leeches, a poultice, and given 
him aperients. His leg, however, had got worse, and I found that 
he had not been attentive to his diet, having already dined off cold 
beef and salad when I saw him. The foot is much swollen, and 
above it, extending over the calf of the leg, there is inflammation 
of the dark-red character of phlegmonoid erysipelas. In one or 
two districts there are small granular-looking points, indicative of 
vesication, and the dark, almost black appearance beneath seems 
to render sloughing unavoidable. The inflamed parts are firm and 
elastic, except in some parts of the foot, where it pits a little on 
pressure ; the wound is scarcely discoverable ; Ms tongue is moist 
at the sides, but elsewhere rather inclined to be dry, and covered 
with a dark-brown fur ; his pulse strong and full ; his abdomen 
large, and a fulness about the region of the liver. Gruel diet, 
bread poultice, twenty leeches to the leg, four grains of calomel 
and three of the pulvis antimonialis, with some extract of rhubarb, 
immediately ; this to be followed by saline aperients, with a grain 
of the tartrate of antimony, every four hours. The next day, July 
13th, he has discharged an immense quantity of dark f accident matter 
from the bowels ; leg less swollen ; foot still inflamed, but does not 
pit on pressure so much as yesterday ; pulse not so strong ; he feels 
better : to continue the mixture, and to repeat the pills to-morrow 
night. Propose to visit him the day after to-morrow ; but he is to 
send if he is not so well. — 15th. Tongue cleaner, bowels open, 
secretions healthy ; leg much better, but two or three patches are 
evidently sloughing ; but the rapid improvement in the inflamma- 
tion seems to suggest that the sloughing will be superficial. — 17th. 
Sloughs separating fast, and granulations are already observable 
at the edges ; the sloughs are evidently superficial ; in all respects 
doing well ; the tongue, however, is rather foul at the back part, 
and he has a good deal of pain when he attempts to move the 
right knee (the erysipelas is in the left leg) ; the right knee is a 
little swollen on each side of the patella, apparently from effusion 
into the bursa ; it is not tender nor discoloured : to continue his 
remedies ; gentle friction to the knee. — 19th. Sloughs separating 
fast ; erysipelas nearly subsided ; tongue clean ; pulse nearly na- 
tural, retaining only a little sharpness. The further progress of 
the case may be stated in a few words : he continued rapidly to 
improve, and, on the 25th, I discontinued my attendance, leaving 
him quite well ; and, indeed, I might have left hi in before this, but 
that, as he recovered, 1 found him rather disposed to return too 



45'J 

quickly to his usual habits. The slough, not withstanding the first 
aspect of the case, proved very superficial ; the affection of the 
right knee subsiding nearly as suddenly as it had occurred. 

I never saw a case more beautifully illustrative of the treatment 
of erysipelas by influences directed to the disordered functions 
than this. The patient was strong and plethoric, and the inflam- 
mation very violent, and just such as I have often seen rapidly 
followed by the worst symptoms. In such a case as this, when a 
a man begins to move about you should support the vessels of the 
limb, at first, by a well-applied bandage, which was done in this 
instance. I believe all advocates for bleeding would have largely 
bled this patient. 



SEVERE CASE OF PHLEGMONOID ERYSIPELAS, TREATED BY 
THE CORRECTION OF DISORDERED FUNCTION, OCCURRING 
WITHOUT ANY LOCAL INJURY. 

A girl, of about twelve years of age, of unhealthy aspect, was 
brought to the Dispensary, with the left arm affected by phlegmo- 
noid erysipelas ; tlie inflammation extended from the elbow to the 
shoulder, and posteriorly to the junction of the arm with the back. 
The inflammation was of a dark-red colour ; the whole arm was 
extremely swollen to the fingers, but ver;i/ tense and elastic, and 
afi"ording the sensation of extensive efliision into the cellular tissue 
throughout. She had been to St. Bartholomew^'s Hospital, where 
she had been ordered poultices and leeches ; but the inflammation 
had continued to get worse, until it reached its present condition. 
The tongue much furred and yellow-brown ; the pulse sharp and 
frequent, 120 ; the bowels habitually costive, and there had been 
now no evacuation for two days. On inspecting the back part of 
the shoulder, there appeared small spots of vesication, and a state 
of subjacent skin which appeared to threaten mortification. The 
girl was very feverish and ill ; in short, it was altogether a severe 
case. 

Regarding this as a. case calculated to test strongly what I be- 
lieved to be the real nature of erysipelas, I ordered no leeches nor 
other bleeding ; made no incisions at the time ; but I ordered the 
child to have nothing but gruel ; and I proceeded to act on the 
bowels by continued small doses of jalap and calomel, with subse- 
quent injections of warm water. The next day the inflammation 



460 



had nudergone no very marked change ; if any thing, it was rather 
better ; nor did the threatening vesications appear to have ad- 
vanced ; the tongue moister, but still fnrred ; she said she had less 
pain, and the powder had produced several evacuations of a dark 
colour and very offensive. I should mention that her mother had- 
allowed her to take a raw apple ; having severely lectm^ed the 
mother on the impropriety of disobedience in a case which threat- 
ened her daughter's Hfe, I desired that the powders should be con- 
tinued, but at longer intervals, so as to keep up occasional dis- 
charge from the bowels ; gruel continued. The next day (Sunday) 
I did not see her ; but a gentleman, who undertook this duty, 
finding the inflammation on the wane, made no alteration in the 
treatment. Monday, I saw her ; she was in all respects improved ; 
the swelling and inflammation much less ; there appeared no attempt 
at vesication ; but the dusky-red was more vivid in that situation 
than elsewhere. The girl seemed very weak, but certainly not so 
much so as she did on her first application ; she had had some com- 
fortable sleep also. Tuesday : inflammation still less ; and, on ex- 
amination, a deep-seated fluctuation, as \Ve thought, was perceptible. 
I now made a moderate-sized opening with a double-edged knife ; 
and by this opening a very large quantity of matter escaped, at 
first streaked with blood, but followed by apparently healthy 
pus. The following day the child was ordered to take a little 
animal food, and got well without any further treatment, except 
a weak infusion of bark with mineral acid. I should mention 
that, after the third day, the evacuations from the bowels became 
natural. 

Now here was as bad a case of phlegmonous erysipelas as is 
often seen, in a very unhealthy subject. The biliary secretions 
and the functions of the bowels were obviously disordered ; the 
means directed to cure the erysipelas, and which were completely 
successful, were the correction of the functions in question. 

Another remark I have to make in this case, — viz. its termina- 
tion in abscess. This is not, as we all know, the ordinary course 
of such cases ; but this is not the only case which induces me to 
believe that the characteristic terminations of unhealthy inflam- 
mation, when it has proceeded too far to be made to subside (or 
terminate, as we call it, in resolution), may be changed to an ap- 
proximation to healthy processes. 

The next case in some measure illustrates this, as it does 
those insensible gradations by which erysipelas and carbuncle are 



461 



connected. In relation to erysipelas in children generally, my own 
experience leads me to think that the bowels are commonly in fault. 
When properly treated, they in general terminate very favorably : 
but I have no experience as to what would happen if bleeding, 
even by leeches, were liberally employed in such cases. Many 
years ago, I saw a fatal case of erysipelas in a very unhealthy 
and emaciated child, about six years old; but I do not recol- 
lect any other example; nor do I remember the particulars of 
that case, further than that the patient had been much affected by 
scrofula. 

I was sent for, a few miles from town, to see a gentleman who 
laboured under inflammation of a phlegmonoicl, erysipelatous cha- 
racter, on the left side of the neck, extending upwards, behind the 
angle of the jaw, and who, besides this, was exceedingly ill. He 
was a remarkably firm, sensible man ; but I found his nervous sys- 
tem in an exceedingly disturbed and depressed condition; and, 
when I entered the room, he could not refrain frcm shedding tears. 
He was naturally of a bilious temperament and sallow complexion, 
and had been ailing for some time previous to his present attack, 
which appeared to have come on the day subsequent to his having 
eaten a rich ddnner — a thing unusual with him ; his habits being 
generally very moderate, and, as regarded drinking, most temperate. 
His pulse was soft, but sharp and frequent ; his tongue was coated 
with a black fur ; his secretions exceedingly wrong ; those of the 
bowels (which had already been opened) being black and foetid ; 
his urine uncommonly thick, and depositing a copious, reddish- 
muddy sediment ; his nights sleepless ; and the skin and conjunc- 
tiva sallow\ There was a dark-red swelling, of a diffused charac- 
ter, on the side of the neck, of a fiery, plilegmonoid, erysipelatous 
character. The centre of this swelling corresponded to the angle 
of the jaw: it was tender; but, notwithstanding its excited appear- 
ance, it was not very painful. I ordered himx to poultice* the part, 
and to take four grains of calomel, with four of antimonial powder, 
and about six grains of jalap ; and I also provided him with a pre- 
scription, of which he was to take, on the morrow, a wine-glass- 
ful, every six hours, according to circumstances, containing six 
ounces of infusion of calumba, with three drachms of ipecacuanha 
wine, and gruel diet. 

The next day, he had taken one dose of the mixture only ; 



* Bread and water. 



462 



the bowels had acted, the secretions being very dark ; and he 
seemed more tranquil. The local disturbance was much the same. 
I ordered a dozen leeches to the part, and the powder to be re- 
peated, with one grain less of the calomel, and to put his feet in 
warm water at night. The leeches bled freely ; as on yesterday, he 
feels a shade better ; the erysipelas was not visibly altered ; and 
the secretions were still very unhealthy. I ordered a mixture of 
equal parts of infusion of senna and calumba, with manna, every 
six hours, and to repeat the pills at night. — To-day, January 5, he 
is much better ; his secretions are improved ; the skin has acted 
freely in the night ; the erysipelas is also better ; that is, it has not 
extended, and, in the circumference, is less violent. T ordered him 
to omit the calomel, and to take pil. hydr. pil. aloet. soap aa, five 
grains at bed-time ; frictions to be made on the region of the 
liver ; and the mixture to be continued. — 6th. The secretions im- 
proved, but still dark; the urine also is better, but still much 
loaded ; the erysipelas varies, but is not essentially altered, except 
that there is evident tendency to a diminution of its diffused charac- 
ter, although the amendment, from day to day^ is so small as to be 
scarcely perceptible. He is certainly better ; and, as he complains 
of want of rest, I ordered him to take five grains of the extr. of hy- 
oscyamus at night, in addition to his pill of aloes, &c. — January 7. 
He has passed a miserable night ; has perspired very little ; and 
his nervous system more disturbed again : he is altogether not so 
well this morning. He was ordered to repeat his pill, without the 
hyoscyamus, but to add to it two grains of ipecacuanha. — 8ih. 
He has had a more quiet night ; his skin has acted well ; and he is 
better this morning. I'he inflammation is less diffused ; but the 
tumour is very vascular, and dark towards its central part. 

It is interesting to observe the changes in the local disease, and 
how these vary with his general condition. The inflammation has 
been losing its diffused character ; but, in other respects, it has 
varied considerably ; sometimes looking less red, as if resolution 
even w^ere not qidte hopeless ; at others, assuming an aspect of ma- 
lignant carbuncle. 

I now ordered him empl. ammoniaci cum hydrargyro to his 
side, and injections daily to the bowels, which he had taken two or 
three times already. — 9th. The tongue is much cleaner ; the tu- 
mour less vascular ; the pulse regular, about eighty, but weak ; 
and the secretions improAdng : he perspires profusely at night ; 
gets some sleep ; and is otherwise not restless : the urine is greatly 



463 



improved, and the countenance less sallow. I directed tlie pills to 
be repeated ; but, as he seems weak, to omit the ipecacuanha. — 
]], 12. He continues to improve; but the tumour at times has 
become painful. — 13. I thought, this morning, I could feel a deep- 
seated fluctuation ; I therefore made a free incision, and very deep, 
giving exit to pus of a healthy character, but the very thickest I 
ever saw. The diminished size of the tumour now discovered a 
smaller collection of fluid, which did not appear to communicate 
with the larger cavity. I therefore made another incision, and 
evacuated another collection. There was some sloughy cellular 
tissue, and a little blood also, discharged. The matter was re- 
ceived in different vessels and also on sponges ; so that I cannot 
say the quantity ; but it must have been very considerable. The 
pills and the poultice to be continued. — 14. The patient is better; 
he has had the best night he has had at all ; his tongue is still 
cleaning, but very foul, and yet black in the centre ; it has always 
been moist. I ordered him to try a little beef- tea or chicken- 
broth; but cautiously. — 16. He is going on well; his tongue is 
cleaning. I had suggested some infusion of bark, with dilute acid; 
but, as he saw I laid not much stress on it, he took only one dose 
of the mixture, 

I need not continue the case ; but may at once add that he 
daily improved, and that his treatment consisted in a gradual re- 
turn to his usual diet, and a gradual w^ithdrawal of all medicine. 
One day, his bowels being torpid, he took a little lenitive electuary, 
with three grains each of rhubarb and jalap, to give it the required 
activity. He came under care at the commencement of January : 
he was perfectly well on the 28th ; the swelling having gradually 
subsided, aud the openings healed, except that, in the larger one, a 
piece of black sticking-plaster was still worn over a small point not 
yet healed. 

The points in this case which interested me were the presence, 
for the most part, of so little pain in an inflammation of as bad a 
character as I ever saw in any carbuncle (with the exception of 
the case of anthrax to be related in connection with that subject). 
At various periods, it might have answered equally well the descrip- 
tions of phlegmonoid erj^sipelas, carbuncle, or even, at one period, 
anthrax. The evidence of hepatic disorder might have suggested 
the more active employment of mercury, as calomel ; but, finding 
that the liver did not refuse to secrete (though but sparingly at 
first), I preferred mild doses of the blue pill, trusting to the efficacy 



461 



given to them from measures directed to the skin and bowels, of a 
gentle kind, arising from the sympathies of these organs with the 
liver ; and endeavouring to avoid imnecessarv depression, or a tedi- 
ous convalescence, or both, of w^hich, in this patient, I was equally 
apprehensive. I was also, in this case, particularly desirous of 
avoiding opium ; for the secretions were in such an unusually de- 
praved condition, that I thought his safety would be entirely com- 
promised by the slightest check of them ; although not copious, 
still they were not suspended ; and the tongue, though as black as 
it ever is in the last stages of typhus fever, was always moist. The 
effects of the hyoscyamus strengthened my fears with regard to opium. 
The injections appeared to produce very comfortable effects, I began 
them first, when, on one occasion, I observed the skin improved in 
appearance, without the secretions from the bowels being very 
satisfactory as to quantity ; and they brought away, as indeed I 
predicted they would, a large quantity of dark secretion. As the 
leeches appeared to do no good, and as I was convinced we had no 
strength to spare, and that they did not minister to the cause of the 
disease, they were not repeated. The moment his secretions pro- 
gressively improved, he was allowed very small quantities of nutri- 
ment ; and, although the disease was severe, and threatening the 
worst consequences, he can scarcely be said to have had any period 
of convalescence, which T attribute to his unflinching adherence to 
the directions given him, and the avoidance of unnecessarily severe 
measures, or even the continuance of any, after the indications ap- 
peared to have been fulfilled for which they were employed. The 
gradual diminution of the diffused character of the inflammation, 
and its termination at last almost wholly in abscess, are to me in- 
teresting features in the case. 

The foregoing cases will exemplify to you the general charac- 
ter of the treatment which I consider proper in erysipelas ; and, 
although there will necessarily be particular points of diff'erence in 
different cases, the principle will be the same in all, — that is, the 
avoidance of excitants, both local and general, and active attention 
to the state of the secretions. If you treat cases in this manner, 
and the}' are presented to you in any reasonable time, — for one case 
of danger, or even great severity, you will see a vast number 
which only present those characters described in the two or three 
first cases which I have mentioned. You must, however, in all, 
very strongly impress on the patient the necessity of abstinence, 
and only allow him weak gruel, or something of the same kind. 



465 



If he requires noiirislinient, this will be sufficient ; whereas, if he 
does not, he will seldom be imprudent as to quantity of this kind 
of diet. 

Your first object should be to clear the bowels, and to keep up 
gentle, but not very profuse, action from them ; and to assist the 
effect this will have on the skin, by the addition of ipecacuanha or 
antimony. Many cases will require no other treatment : in others, 
again, a few active doses of calomel will be of great service, and 
especially in cases where the liver may be demonstrably in fault, 
or reasonably suspected to be so. To this you may advantageously 
add some sudorific ; as ipecacuanha, or, still better, antimony. In 
some, as in a case selected in a preceding Discourse, its combination 
with small doses of opium will be found useful ; but, generally, this 
is not necessary. In severe cases, should the calomel, however, 
affect the bowels profusely, you will obtain much advantage by 
moderating this effect ; and one-sixth of a grain of opium, or two 
or three grains of the opiate confection, with two or three of ca- 
lomel, according to circumstances, will be useful. I would observe 
that I have, however, generally tried to avoid opium, or given it in 
very small doses, from the fear of checking the secretions ; -a free- 
dom in regard to these, as distinguished from inordinate excitement, 
being of all things most important in erysipelas. Mr. Lawrence 
appears to employ calomel and James's powder, in the proportion 
of three or four grains of each with saline aperients, with or with- 
out antimony, and according to circumstances. This is also, in 
active cases, very good practice. Where calomel disturbs the 
bowels more than is desired, and you are reluctant to employ any 
narcotic with it, you will sometimes find the addition of a few 
grains of powdered cinnamon, or some other aromatic substance, an 
useful auxiliary. Injections of warm water are also of great ser- 
vice, as I have already noticed in speaking of inflammation. 

I have seen very little evidence from which I can safely draw 
any conclusion in regard to the use of bark or stimulants in erysi- 
pelas. Those who place so much reliance on bark, appear to me 
to commit the same sort of error as those who advocate bleeding 
and evacuants as such. The former look chiefly to the absence of 
power ; the latter, too exclusively to the presence of excitement : 
the true view is, that which combines a sustained impression of 
both. I would by no means, however, assert that, in certain cases, 
the exhibition of bark may not be useful ; whilst in any which we 
may see for the first time, when extensive sloughing has already 

H H 



40() 



taken place, it may prove more useful than any other medicine. 
From the evidence of writers on this subject, and especially that of 
Drs. Wells and Fordyce, it appears probable that bark may, in 
some cases, correct certain conditions of the stomach and alimen- 
tary canal, or of the system on which the erysipelas may de- 
pend ; and any thing that will do this, will become a good 
remedy in the case to which it may apply. It is also probable 
that, in different cases, and at different periods, erysipelas may 
be more or less connected with disorder of particular organs, 
though its essential characters be the same. So also the indication 
of want of power may take the lead in one set of cases ; that of 
excitability in others : and again, they may be, as is the common 
case, pretty equally demonstrated. I think it certain that any 
thing which gives power without adding to excitement, would do 
good in erysipelas ; and that bark, auspiciously administered, does 
this in some other cases, is, I think, not to be disputed. But then 
it usually requires some previous correction of the secretions ; 
and this, in erysipelas, generally renders bark unnecessary. 

I have given bark often enough in erysipelas, according to re- 
ceived notions ; but then it has been under circumstances where I 
verily believe it to have been unnecessary ; because I have often 
found patients neglecting the bark, whilst they have continued the 
plain, cautious, but more nourishing diet recommended on the re- 
tirement of the erysipelas ; so that in private practice I seldom 
employ it when I can place dependaiice on the steadiness of the 
patient : when I cannot do this (in dispensary practice, a very fre- 
quent case), I prescribe either the infusion or decoction, either alone, 
or sometimes, if the bowels require it, with a little manna in solu- 
tion. I have sometimes also thought that infusion or decoction of 
bark, with small doses of the dilute sulphuric or nitric acid, assisted 
in restoring the digestive functions. Usually, however, I regard 
the case at this period as really requiring notliing but a cautiom 
return to a moderate diet. A due observance of this is, however, 
more secure, if the patients be still taking some medicine ; for, if 
they are improving without any, it is often difficult to persuade 
them that the required prudence in diet is necessary. 

I have thus stated what my experience has led me to think 
concerning bark ; but I would have you take my observations in 
regard to that medicine with caution, and observe for yourselves 
those cases in which you may see it administered. As this is the 
first time I have mentioned bark, I may observe generally, that 



467 



wherever I have employed this remedy, I use the infusion or de- 
coction ; and I prefer this form to the quinine. I here speak of it 
generally, not merely in regard to erysipelas. I have often seen 
bark, in infiision or decoction, beneficial where the quinine, even in 
very small doses, produced excitement ; and I have not found 
quinine do where bark disagreed : but then I have seldom given 
bark in those masses in which it is sometimes, or, at all events, 
was formerly, prescribed. Physicians, however, have more ex- 
perience on such subjects than surgeons ; I only here state the 
results of my own experience. In all cases of erysipelas, when 
properly indicated, a free opening or incision is highly advan- 
tageous ; but, as this is one of the points on which I must speak a 
little more at large, I refer you to a succeeding page for instruc- 
tions on this subject. 

I must now make a few observations on bleeding in erysipelas, 
and also on the local measures which should be employed. 

TREATMENT CONSIDERED GENERALLY. 

Bleeding, as I have before observed, is the great point of diffi- 
culty with practitioners in general, in regard to the treatment of 
erysipelas ; and here, as in all other cases, we must begin by 
collecting facts. Many of these are of the same kind as those 
mentioned in relation to inflammation generally ; but with this dif- 
ference, — that those which oppose the idea that bleeding is the 
proper remedy for erysipelas, apply with much greater force, in 
that they are of far more frequent occurrence. Now we find that 
erysipelas gets well when bleeding has doubtless been employed ; 
we find that numerous cases also get well without bleeding : and, 
as regards general bleeding, the number is probably much greater 
than those in which bleeding has been instituted. We find also 
that bleeding is never trusted to alone in erysipelas : and more 
than this, that it is not only employed with other remedies, but 
with remedies which, when employed without bleeding, have been 
proved over and over again, in a great many cases, to be successful. 

We find, it is true, great difference of opinion on the adminis- 
tration of this remedy : that is, we observe that some are decided 
advocates for it ; some only employ local bleeding ; some only bleed 
in particular cases ; some almost entirely reject it. But we never 
fail to observe some evidence of caution in regard to it. There is 

H H 2 



468 



a practical recognition in all writers, that it is not a remedy of 
nniversal applicability : wliilst the necessity of attention to the 
various functions, and particularly the chylopoietic viscera, is 
allowed by all, and in all cases ; so that, when we regard the dif- 
ferences of opinion on the subject of bleeding, they are shaded off, 
as it were, from those who almost exclude bleeding, to those who 
are strong adv^ocates for it : these last, however, not recommend- 
ing that indiscriminate use of it, which they do in what they 
regard as common inflammation. Even Mr. Lawrence, who seems 
to employ bleeding in this complaint more freely than most others, 
does not appear to bleed in all cases. 

Now all this is quite reconcileable with those views which limit 
the notion of inflammation to an excess of blood in a part, or of 
excessive action, or both. Since, with views so limited, nothing is 
more natural than that different degrees of inflammation may re- 
quire different modes and degrees of bleeding, nor more consistent 
with them, than that some bleeding should take place in all. That 
this is the key to the greater part of the differences of opinion observ- 
able on this subject is plain : w^hile, from the fact, that those who 
recommend bleeding in erysipelas, always rest their recommenda- 
tion on its inflammatory character ; whilst those who oppose its 
employment, proceed on the assumption that it is not so. Thus, 
Mr. Pearson, as I have shewn, is on the whole opposed to general 
bleeding ; and, exactly in the same ratio, doubts its inflammatory 
character, — that is, he neither absolutely rejects either. But whilst 
he speaks of bleeding in large towns as seldom necessary, or even 
admissible,"' he says the relation of erysipelas to inflammation is 
" very remote." 

The error under which we have laboured is plain enough, and 
the cause of it equally so ; — the cause being the absence of true 
views of inflammation ; and the error, a notion that inflammation 
necessarily required the abstraction of blood. It never seems to 
have occurred to us that the quantity of blood in the system 
might have nothing to do with the matter. It never seems to have 
occurred to men that the views to which they limited their notions 
of inflammation might have nothing to do with the real cause of 
the process ; or that this cause might involve agencies, to the 
removal or correction of which, bleeding might be in one case un- 
necessary, in another injurious. If, notwithstanding this error, 
however, the treatment of cases had been conducted with a view 
to the legitimate induction of any conclusion as to the effects of 



469 



remedies, it might very possibly have led to the correction of the 
practical error, although it might not necessarily have explained 
the circumstance on which it depended. 

I have already alluded to many writers ; but there is one of more 
recent date, on whose observations on this subject I must make a 
few remarks. Mr. Lawrence, of St. Bartholomew's, has written 
a paper in the Med. Chir. Transactions, on Erysipelas, in which his 
object seems to be to shew that it is an inflammatory disease ; that 
it most frequently arises in persons who live irregularly, or who are 
not very cautious at least in their habits of living ; and that the 
treatment is essentially anti-inflammatory, especially demanding, in 
certain cases, the employment of bleeding and incisions. Now, in 
most points, I agree with Mr. Lawrence ; but there are some in 
which, consistently with the views which I have endeavoured to 
develop, I differ ; and the chief of these is on the subject of bleed- 
ing. I am the more desirous of considering this point, since T 
think the paper likely to mislead in regard to this remedy, not only 
because Mr. Lawrence is justly regarded as a good authority, but 
for a still better reason — the general excellence of the paper. 
Now, were it necessary, it would be easy to oppose the authority 
of Mr. Lawrence by others ; but this, though often expedient in an 
argument, is of little value in the pursuit of truth : it would help 
me very little in any difference of opinion, to shew that others 
differed also. The question is, not w-lio differs, but the grounds on 
which the tw^o opinions may rest. The general reasons on which 
I dissent may be gathered from the preceding pages ; those having 
a more direct reference to Mr. Lawrence's paper I will proceed to 
state. 

Now, supposing that we knew nothing about erysipelas ; sup- 
posing that we had never even seen a case of this disease ; it would 
be exceedingly difiicult, w^ith any approximation to inductive rea- 
soning, to conclude, from Mr. Lawrence's paper, that bleeding was 
a good remedy in its treatment. We might possibly infer from the 
paper in question, that it was not necessarily injurious ; that, in 
some rare cases, it might prohally be necessary ; that in others it 
was disadvantageous : but we could not, I conceive, in conformity 
with the ordinary rules of induction, by any means establish a 
well-grounded confidence in this remedy. You should read the 
paper cautiously, and you will then see how far my observations 
' are reasonable or otherwise ; and I particularly wdsh this, from 
I my limits not affording me the opportunity of making that ana- 



470 



lysis of the paper in question wliieli its general excellence de- 
serves. I will, however, make a few remarks on it. 

We observe that the bleeding was employed, in conjunction 
with other remedies, with remedies that exert a very powerful in- 
fluence in the relief of erysipelas ; and that, too, in cases where no 
bleeding has been instituted. I must, however, guard you from 
supposing that Mr. Lawrence advocates the indiscriminate use of 
bleeding ; on the contrary, the following passage, although it seems, 
taken -with the whole paper, to refer to exceptions rather than the 
rule, in a practical sense, though in a limited manner, fully recog- 
nizes the true principle on which the complaint should be treated. 
" The disposition* of erysipelas," says Mr. Lawrence, " to termi- 
nate by resolution, is another reason against resorting indiscrimi- 
nately to active depletion. In many cases, the disease passes 
through a certain course, and ends spontaneously ; it is sufficient to 
put the patient on low diet ; to cleanse the alimentary canal ; and 
then to use mild aperients and diaphoretics. When it proceeds, as 
it often does, from unhealthy conditions of the alimentary canal, the 
removal of the internal disorder leads to the cessation of the local 
complaint. It must be observed, however, that veneesection is 
sometimes useful, both in curing the internal causes of erysipelas 
and in promoting the termination by resolution." 

Now, an extension of the view, unfolded in the first part of this 
passage, is really, I believe, the right treatment ; but, nevertheless, 
it is impossible not to perceive that, in a practical sense, Mr. Law- 
rence is to be regarded as an advocate for bleeding, and that in no 
very measured manner. For example, in case the 8th, a man of 
fifty years of age, of a robust and plethoric habit, &c. receives a 
slight wound of the scalp from a fall, on which erysipelas super- 
vened, and for which he had been thrice bled to the extent of 
twenty ounces " on each occasion," and subjected to the other parts 
of the antiphlogistic treatment. Mr. Lawrence adds, " when I saw 
him, at the end of this time, the scalp on the left side of the head 
was slightly red, and raised into a general elevation, apparently by 
matter diffused, through the cellular texture under the aponeurosis 
near the wound, and by serous effusion in the circumference. 
There was a small opening through the inflamed and swollen scalp, 
on the left parietal bone, the original wound, and another about 
three inches further back, which had been made to let out matter. 



* My experience leads me to doubt this " disposition" (treatment apart). 



471 



Through these, a well-formed pus could be squeezed ; the lace was 
red and swollen with erysipelas ; the tongue was of a dirty -white 
all over, and rather dry ; the pulse full, but not very strong. As 
the openings were manifestly inadequate to the discharge of matter 
which could be pressed towards them from a considerable distance, 
and as the suppuration was extending under the aponeurosis, I laid 
the two apertures into one, dividing an artery which bled freely. 
This w^as allowed to bleed on, as I thought a further loss of hhod 
necessary, although the patient was averse to the measure. The 
bleeding was continued until the faintness came on, when the artery 
was tied. The blood which had been caught in a basin amounted 
to more than twenty ounces (tw^o grains of calomel w^itli two of 
James's powder were given every six hours ; saline medicine, with 
saline aperients ; milh diet). Mr. T. slept w^ell ; was much better 
the next day, the tongue being particularly improved. He con- 
tinued the medical treatment, with slight variations ; the inflamma- 
tion and suppuration of the scalp were arrested ; but the erysi- 
pelatous redness and swelling passed over to the opposite side of the 
face. In about a week, he began to take the suhcarhonate of 
ammonia, and he recovered quickly and completely." 

This case is very interesting. A man, in whom we might cer- 
tainly have expected most benefit from blood-letting, and whom 
many people would have bled in some shape or other, loses sixty 
ounces of blood, and is subjected to a general antiphlogistic treat- 
ment, without, so far as we can see, receiving any benefit from it. 
Matter forms under the scalp, which, appearing confined there, is 
very properly evacuated by a free incision, from which he is al- 
lowed to lose twenty ounces more. Now he has calomel, &:c. as 
related. I can see no clear evidence of the good effects of bleed- 
ing in this case ; but it is probable that the free opening was of 
great service : the reader, however, may form his ow^n opinion. In 
other cases, the difficulty of adjusting the influence of blood-letting 
depends on the simultaneous employment of calomel, antimony, 
and saline aperients ; all of which exert great, and I should say a 
much greater, influence in this disease than bleeding ; calomel and 
antimony more especially : not only, in a general sense, by the de- 
termination to the surface, and the power of equalizing the circu- 
lation which they evince, but also by the effect they produce on an 
organ so frequently at fault in these cases as is the liver. 

If the object were to obscure the effect of blood-letting in ery- 
sipelas, you could evidently not do so more effectually than by 



472 



employing with it such remedies as are known to possess most 
power when employed ivitliout blood-letting ; and, for my own 
part, I know not any that answer this description so well as 
calomel, antimony, and saline purgatives, in their general applica- 
tion. I wish to impress this the more on you, because I beheve it 
to be one of our greatest errors ; whilst it is quite fatal to all in- - 
ductive reasoning. Undoubtedly we labour under great difficulties 
in severe cases : we are anxious to leave nothing undone which 
may be beneficial ; and we are too apt to regulate our treatment by 
what is regarded as conventionally the best of the day, than to re- 
flect for ourselves on the indications of the individual case. But, 
in hospitals, we have peculiar advantages in substituting more 
rational modes of practice ; and opportunities not only of controll- 
ing the imprudent interferences of patients, but of watching the 
effect, and of immediately superadding any part of the treatment 
which a more inductive mode of proceeding may have left unem- 
ployed. Even in dispensary practice, encompassed with difficul- 
ties, and harassed by vexations, of which those who have not 
experienced them have little idea, considerable approximations may 
be made to a practice allowing of a more close mode of reasoning ; 
as I hope to shew in relation to various diseases in due time. 

1 add one more case from Mr. Lawrence's paper. The case is 
headed Erratic Erysipelas, treated by Vensesection. " Wm. Mc 
Donald, set. sixteen, came into St. Bartholomew's Hospital on the 
30th of September, 1826. He had been discharged from the hos- 
pital only a week since, having had a lacerated wound of the arm, 
which was nearly healed. He has since been indulging himself 
with a very full diet, and has used the arm freely : violent inflam- 
matory fever, with erysipelas of the arm, has taken place. — Sep- 
tember 30. I ordered immediate vencesection to twenty ounces ; senna 
mixture ; and, afterwards, saline draughts with antimony. — October 
1. Redness and inflammation rather increased. Repeat the vensesec- 
tion to fourteen ounces ; three grains of calomel every eight hours. 
— 19th. The erysipelatous redness gradually spread over the head, 
the trunk of the body, the opposite arm, and the lower limbs, sub- 
siding in one part, and spreading successively to others. He was 
kept on low diet. The saline medicine w^as continued without the 
antimony, the latter having made him very sick ; occasionally, pur- 
gatives were employed, and he gradually recovered. The extent 
and continuance of the disease, and the consequent reduction of 
strength, excited great alarm for this patient ; but the expression 



473 



of the countenance, and more particularly the state Of the eye, as 
well as the voice, were natural throughout. The disturbance of 
the system was always inflammatory during the whole progress of 
the case ; the pulse excited ; the skin hot and dry ; the tongue 
white. Neither bark, ammonia, nor any other stimulus could be 
borne ; every trial of such means, however cautious, aggravated 
the disorder. The recovery of strength on the cessation of the 
inflammation was very rapid." 

I confess myself entirely at a loss to perceive the evidence of 
this boy having been at all benefited by the vensesection. It 
seems to me that Nature here spoke so emphatically, that (the bleed- 
ing apart) the case was treated, in the main, properly. The ery- 
sipelas sets in, on a wound nearly healed, after a full diet and iree 
motion of the part : and, whilst the weakness of the boy on the 
one hand seems to have prohibited any further extension of 
the bleeding, his excitability on the other rendered ammonia, 
bark, &c. experimentally inadmissible ; so that, in fact, the treat- 
ment became resolved into that which struck at the cause ; viz. 
aperients, low diet, and rest of the part, which last, though not 
mentioned, I take for granted : whilst it is not unreasonable to sup- 
pose that the bleeding (recollecting that it was a boy of sixteen) 
might readily enough contribute to his debility ; as it certainly did 
in a case mentioned in a former discourse. Compare this case 
with the case mentioned in the previous discourse (page 379). So, 
in regard to the cases treated by incision, we have, in case 25, a 
pretty good evidence that the bleeding did no good. I would also 
direct attention to those cases in which bark or stimuli were em- 
ployed, with a view to the consideration of the circumstances which 
rendered them necessary ; and, in fact, to the whole of IVIr. Law- 
rence's paper, which is altogether the best that I know of : and, in 
pressing your attention to it, I do so, first, for the reasons already 
assigned ; and, secondly, because I would protest against any conclu- 
sion being formed on that paper without the perusal of the whole of 
it, since you may not arrive at the same conclusions which I 
have done. But I cannot help thinking that bleeding was em- 
ployed very unnecessarily, on the evidence of the cases themselves ; 
and that Mr. Lawrence would think so too, vi ere he to conduct the 
treatment of a few cases in the manner and on the principles which 
I have already described as applicable to inflammations generally. 
You will, however, perceive that my doubts, in regard to the neces- 



414 



sity of bleeding, must naturall)' be increased by the results of my 
own experience*. 

Now, in relation to erysipelas, I have seen as much of it as 
most people ; for, whilst few have had better opportunities, I trust 
I have not been idle in relation to their cultivation. I believe I 
have seen the disease in every form, and under almost every - 
variety of circumstance, and have had to treat it under various 
difficulties, in dispensary practice, which we seldom experience in 
private, and which is altogether unknown in hospitals. In a very 
large, poor, and populous district, like that included in the Finsbury 
Dispensary (singly considered), by far the greater field of my ob- 
servation, it may be readily conceived that, in seventeen years, I 
must have seen not a few bad cases also. When I began practice, 
I felt strongly impressed with all that Mr. Hunter had written 
(which was then published), and which IMr. Abernethy had taught ; 
because both one and the other appeared to me to be more like 
common sense than anythiug I had seen or read elsewhere, and 
therefore more philosophical. xVbove all, I was impressed with 
nothing more strongly than the distinction (on which both these 
distinguished ornaments of the profession so strongly insisted) to 
be made between excitement and power, of which every case of 
erysipelas afforded an emphatic demonstration. Moreover, I soon 
perceived that excitement and power were not only very distinct 
things, but that, as power diminished, excitement seemed often to 
increase, as if it consisted in an endeavour to supply the place of 
power. I soon found, also, plenty of examples illustrative of the 
influence on all diseases exerted by derangements of the digestive 
organs, which I saw often, and indeed generally, produced excite- 
ment, but which always diminished power. 

Notwithstanding, therefore, that I regarded erysipelas as essen- 
tially an inflammatory disease, it will not be wondered at that I 
was rather careful in regard to the abstraction of blood — a due 
quantity of which I believed to be necessary to power, and which 
I soon found was much more easily withdrawn than supplied. 
With these notions, in some cases, I bled pretty freely ; but this 
happened but seldom : in other cases, I left bleeding out altogether ; 

* Although the text sufficiently declares ray own opinion, yet the student should 
always be guarded when an author points to any sweeping generalization. There 
ma// be cases requiring bleeding in the manner recommended by Mr. Lawrence ; 
I do not meet with them ; and I am disposed to think them very rare. 



475 



in others, I delayed bleeding, but often with great anxiety and 
labour, from the vigilance it necessarily implied, lest I should have 
omitted a remedy which ought to have been employed ; whilst, in 
all, I paid great attention to the digestive organs, which, though at 
first of a general kind, still included very spare diet, open bowels, 
and generally measures having for their object the reduction of 
action and determination to the skin ; as tartrate of antimony. But 
the course of experience gave me more confidence ; since I not 
only found cases do well without bleeding, or with such bleeding as 
leeches only afforded, but even those in which I bled, inasmuch as 
I employed other remedies at the same time, often led me to doubt 
whether much benefit really resulted from the bleeding. 

Then, again, I saw many cases elsewhere ; and it appeared to 
me that a much greater success attended generally on treatment 
which either implied only a very measured abstraction of blood, or 
in which it was altogether withheld. I saw patients dying of ery- 
sipelas not very unfrequently ; whilst those in the dispensary very 
rarely died ; and, in almost every instance, the fatal result was 
clearly referrible to gin-drinking, or other equally gross violation of 
the injunctions I had given. I recollect a case in which a very 
severe erysipelas of the arm, threatening mortification of the whole 
member, v^as progressing most favourably (as severe a case as I 
ever saw or read of) under spare diet and an improved state of the 
secretions, when, all at once, affairs which had been going on so 
prosperously were changed by an alarming exacerbation of sym- 
ptoms. The inflammation in twenty-four hours had recurred with 
unusual vehemence ; the patient had become delirious ; and, as it 
appeared to me, past all hope. I sat down to investigate the causes 
of this sudden alteration ; and, although my questions were press- 
ing, still the people about the patient could not, or would not, afford 
me any explanation : at length, a woman came in, who declared 
that the patient, to her knowledge, had taken half a pint of gin and 
a pint of porter, which then the other persons also acknowledged. 
This patient soon sank into a state of torpor, and died. It is diffi- 
cult to say much of our ov^n practice without the appearance of 
egotism ; but I can very safely affirm, that, where my injunctions 
have been followed, I have very seldom seen erysipelas fatal ; and 
I state this with the less hesitation, because, although my public 
practice has been solitary in regard to its responsibility, in former 
years, to a degree often highly painful, — yet it has never been so 
as regards the presence of plenty of witnesses. I know not that 



476 



ever I treated a severe case of erysipelas which has not been ob- 
served bj at least two or three pupils, and often by practitioners 
also, who occasionally pay me visits at the dispensary ; so that the 
number of persons who have seen both the general practice and 
the general results, of about seventeen years, is very considerable. 
I bleed in erysipelas now very rarely, otherwise than by leeches, 
which, in many cases, seem to check the inflammatory actions, and 
give time for the operation of remedies which strike more at the 
cause of the disorder. I do not say that general bleeding may 
never be necessary ; you do every now and then see cases where 
a generally fall habit seems to suggest the expediency of this 
remedy. If you do bleed, I think you will do best by bleeding so 
as to make a decided, but quick, impression on the action of the 
heart and arteries, not regarding quantity so much as this effect ; 
but, if your bleeding does not obviously and materially influence the 
inflammation, be careful how you bleed again ; for it is my firm 
opinion, that, in the vast majority of the cases, you will do harm : 
you will either risk your patient's life, or render his recovery pro- 
tracted, and requiring wine, bark, &c. — not as the consequence of 
the disease so much as of your treatment of it. 

In no case should I bleed at the commencement ; because I am 
certain that in those which, according to received notions, most 
strongly suggest the remedy, it is often unnecessary : and I never 
can believe that any remedy which is unnecessary can be otherwise 
than more or less injurious ; still less one so powerful as abstraction 
of blood. The quantity of blood which the system will bear the 
loss of, under circumstances of excitement, is surprising ; and I 
feel certain that this is the reason why so much advantage has 
been attributed to the remedy: apparent present impunity is mis- 
taken for advantage ; and the prospectively inj urious debility, due 
to the bleeding, referred to the erysipelas. In my own practice, I 
seldom repeat even leeches where one liberal application of them 
(from twelve to twenty or thirty, according to the case) has elicited 
no improvement ; but they are very useful as clipcking inflam- 
matory excitement, whilst they produce, in their ordinary applica- 
tion, very little reduction of power. 

The connection of erysipelas also with disorder of the general 
health has been so often demonstrated, that I now know pretty 
well what to expect, although the local demonstration be but 
slight. I recollect one case, which was not under my treatment, 
of a man who came to my house one morning with a wound in 



bis tliumb. He was a butcher ; and, in endeavouring to stop a 
pig-, one of the tusks had grazed his thumb, and there was a small 
patch of erysipelas occupying the circumference of the site of the 
wound. I observed that the man's countenance was sallow, and 
particularly unhealthy. I was therefore very particular in my 
directions as to what he was to do, and especially in regard to 
keeping at home. I heard no more of him ; for, not knowing, it 
seems, that he might be visited, he had not sent his letter as the 
printed form on it directs ; he had availed himself of the services 
of some gentleman who was attending a patient in the house w^here 
he lived. Now, on Friday, the day of his application, I said to 
the pupils, on his leaving the room — " There, now, is a case appa- 
rently very trifling; but it would not surprise me if that man 
died." On the Tuesday following, when I went to the Dispen- 
sary, not having heard anything of the man, I made enquiries for 
him, when I found that he had died that morning, having been 
attended by another surgeon, as already stated. 

The local treatment of erysipelas should first consist of abso- 
lute quietude of the part, and the envelopment of the inflamed 
surface, and that in its immediate vicinity, in a soft, w^ell-made 
b!"ead-and- water poultice, made without any addition of oil or 
grease, or anything of that nature. I avoid cold applications ; they 
give a check to the actions at the surface, without acting on the 
cause of them ; and, except when the feelings of the patient 
strongly suggest their trial, should be regarded as neither useful 
nor safe. Of leeches I have sufliciently spoken. In regard to 
incisions, so much spoken of in erysipelas, they are, in many cases, 
of the greatest advantage ; although I am somewhat unfortunate in 
not being able to agree entirely with either of the two gentlemen 
who have written chiefly in their recommendation — I mean Mr. 
Copeland Hutchinson and Mr. Lawrence. The former makes a 
number of small incisions : he says they may be " about an inch 
and a half in length, two or three inches apart, and vary in num- 
ber from six to eighteen, according to the extent cf the surface the 
disease is found to occupy." I cannot perceive the advantage of 
this proceeding ; and I feel certain that it is unnecessary. It 
increases the pain, and afl"ord3 additional risk of dividing arteries ; 
which appears to me not to be amongst the advantages of this 
mode of practice. Mr. Lawrence makes one sweeping incision, 
seldom more than two, along the line of the inflamed part ; and 
seems rather to run into the opposite extreme. Besides which, Mr. 



478 



Lawrence allows a quantity of blood to be lost, which, in my 
opinion, is neither necessary, advantageous, nor, as his own experi- 
ence shews, always safe. The simple view which I take of these 
incisions, and of the advantages resulting from them, induces me 
to adopt a measure intermediate betw^een the two. I see Nature 
labouring to determine an action to the surface, just as I do in boil, 
carbuncle, effusions of urine, supplying deficient power by excite- 
ment : I know that she will only do it by extensive sloughing, 
which requires an increase of subsequent exertion in the repair 
which becomes necessary. If, under treatment, I perceive the 
actions diminishing in the circumference, and determining to a 
particular spot, I either do nothing, or make a good, free opening, 
according as I think resolution still probable, or otherwise. If!, on 
the other hand, I see that the inflammation is extending, or becom- 
ing increased in the site it already occupies, I make a free incision, 
the centre of which corresponds to that of the inflamed surface, 
and which may occupy a third, scarcely ever half, of the whole, 
fairly through the cellular tissue to the fascia beneath it, which, if 
also divided, is of no consequence. I know that this will unload 
the cellular tissue ; because I know that that perfect adhesion of 
this structure which takes place in more healthy inflammation is 
not present ; and, lastly, because experience has shewn me that 
nothing more is necessary. With regard to the bleeding, which 
Mr. Copland Hutcliiiison seems to regard as advantageous, and 
Mr. Lawrence in a still greater degree, my experience in erysipelas 
naturally makes me sceptical as to the advantage of any great loss 
of blood on these occasions ; whilst that resulting from free open- 
ings, in all cases of inflammation of the surface which cannot be 
brought to subside or terminate in resolution, applies to all cases, 
and is especially exemplified in carbuncle : neither do we find, so 
far as I know, any relation between the adrantayes resulting from 
such openings, and the quantity of blood which may be lost from 
them. Erysipelas sometimes is not continuous, as it were ; but we 
find the inflammation concentrating itself on more points than one, 
the intermediate surface being comparatively but slightly inflamed : 
in such cases, no doubt the incisions should be made over the 
respective foci (so to speak) of the inflammation. In conformity 
with such views, if the bleeding do not cease of itself after a few 
minutes, I should advise you to raise the limb, to apply cold water, 
or tie any vessel, the size of which may suggest the necessity of 
such a proceeding, which I apprehend will be very rarely neces- 



479 



sary; nor indeed any other measure beyond elevating the limb, and 
not renewing the application of the poultice until the bleeding shall 
have ceased. 

I have stated that this poultice appears to me the best applica- 
tion ; it tends to the reduction of temperature by evaporation, and 
also solicits the action of the skin to which it is applied ; and, be- 
sides this, is generally very agreeable and soothing to the patient ; 
and, if there be much pain, it may often be made with poppy- 
water or some other narcotic solution w^ith advantage. When sup- 
puration has become established, the linseed-meal poultice may be 
applied without injury. I think, in some cases, the patients find 
it more comfortable ; but, generally, if I can ensure its being well 
made, and sufficiently large, I prefer the bread and water. 

In all cases of erysipelas, whatever their form or their severity, 
the principal point is to find out the general disorder of the body 
on which the erysipelas depends ; and, if possible, the organ most 
especially in fault, or most concerned in the causation. It is, there- 
fore, so far the treatment common to all inflammations, with this 
material circumstance — that as the general powder is less, so can 
you place less reliance on such measures, which (whatever their 
other effects may be) involve any serious diminution of that power. 
I cannot give you any other directions on this head, than those 
already offered in regard to inflammation generally, except that I 
would advise you to look w^ith particular suspicion to the liver ; 
and never neglect to examine^ not only the region in wdiich it lies, 
but the abdomen generally, to see if there be any tenderness 
on pressure. I recollect being shewn a case of erysipelas which 
seemed neither to progress favourably nor otherwise, but which 
appeared to be stationary. I found no examination of the abdo- 
men had been made, though the patient was under the care of a 
very distinguished surgeon. I just made pressure on the region of 
the liver, and the part was so tender that it might have almost 
suggested the idea of inflammation of the peritonaeum ; yet there 
was no pain when the pressure was remitted. 

In those cases which are chiefly marked by inflamed absorbents, 
with or without erysipelas of the limb, and in those resulting from 
dissection, I see no difference in the treatment required. The es- 
sential cause is the same, — viz. a disturbed condition of the system : 
but all the cautions, in regard to bleeding, apply with especial force 
to cases the result of dissection. 1 believe I have seen a student as 
demonstrably killed by injudicious bleeding, as i£ he had been 



480 



killed by a direct injury of any other kind. In many of these 
cases^ independently of the general disturbance of the system, re- 
sulting from causes common to erysipelas and inflamed absorbents, 
when occurring under other circumstances, there is frequently 
superadded, that resulting from the idea of the absorption of poison, 
and the apprehension of danger. I am convinced that here the 
abstraction of blood is in the highest degree dangerous : as a most 
emphatic example of this, a patient, a young man, apparently 
strong, lost only about twelve ounces of blood, yet the effect it 
produced in the rapid declension of power, and the supervention 
of cerebral excitement, left no doubt on the minds of any who saw 
him (not excepting the gentleman who bled him) of the injurious 
tendency of this bleeding. 

In the prevention of erysipelas, certain cautions appear useful, 
and these apply of course with greater force to all those who live 
in large cities, and especially those whose occupations are un- 
healthy. Wherever a wound is inflicted, however trifling, it should 
be carefully and effectually cleansed ; after this, the part should be 
protected from the atmosphere by a piece of goldbeater's skin or 
sticking-plaster, and kept perfectly quiet until healed. I do not re- 
commend this with any notion of a poison being present, but with a 
view to the general removal of any irritating matter which may be 
on the part ; and especially closing the wound from the influence 
of the atmosphere, and keeping it quiet. 

There is something in the closure of wounds which is very 
important. The skin evidences an elaborate contrivance of Nature 
to keep parts, not naturally intended to be exposed to them, from 
atmospheric or some other external agencies. The extraordinary 
difference between simple and compound fractures is in no way 
explicable by the mere laceration of the skin, implied in the latter, 
abstractedly considered. The fact also, that exposure to the air 
generally gives pain to an enlarged surface, is worthy of attention : 
it is excitement of nervous action ; and if we can perceive nothiug 
else, we can see that, in the atmosphere, we are at least applying 
a combination of two gases to the womid, which experience shews 
to be neither necessary nor advantageous. We should also be im- 
pressed with the fact, that in all these cases the inflammation 
shews an absence of that provision which in healthy states of the 
oeconomy ser^'es to limit the inflammatory process ; wherefore, 
however small the inflammation be, yet, if it be of a diffused cha- 
racter, we should always be vigilant and suspicious. 



481 



My friend Mr. Wormald, Demonstrator of Anatomy at St. Bar- 
tholomew's, considers that the occasional results of dissection have 
occurred much less frequently since he has adopted the use of a 
wash, consisting of a solution of alkali. The part supposed to be 
punctured is washed with this solution ; which he says, by the little 
smarting it produces, will often discover a puncture which might 
otherwise have escaped detection ; after which the pupil is directed 
to wash the part. Probably cleanliness with soap and water, as 
already recommended, with the additions described, are the essen- 
tial prophylactics : but I state the fact as mentioned to me by Mr. 
Worm aid. 

It has been recommended in certain cases, by Mr. Higgin- 
botham, to apply caustic to slight wounds or abrasions ; and also 
to rub caustic around the line which circumscribes the erysipelas. 
In some cases this seems to have done good ; as regards the wound, 
it makes a new surface, practically for the time, around the part. In 
erysipelas, it so far simulates the adhesive circumscription of healthy 
inflammation, as interposing a different part between the skin which 
is affected, and that which is not so ; practically, it breaks the 
continuity of surface as regards the identity of structure. I have 
no experience in matters of this kind. As having little to do with 
the cause, I should have no confidence in them, whilst experience 
convinces me that other measures are attended with less risk, 
and are more efficient : but perhaps they have not yet been 
sufficiently tried to enable us to adjust the degree of merit due 
to them. 

One thing appears certain — that they can, in severe cases, never 
supply the place of the more efficient treatment ; although, in 
interrupting continuity of surface, we can easily perceive how the 
caustic, applied around or above inflammation, might, as a sub- 
ordinate measure, prove useful. 

Pressure has also been applied, extending above the inflamed 
part; a practice recommended, I believe, by M. Velpeau : but 
those who have seen much of erysipelas will not be disposed to 
place much reliance in such a measure : whilst, if it does not 
succeed, it may readily, as experience has shewn, aggravate the 
mischief 

I have thus endeavoured to lay before you the treatment of 
erysipelas, by which you will perceive that it is essentially that of 
any other inflammation. That it consists in equalizing the circu- 
lation, in endeavours to remove the disturbance with which it is 

I I 



482 



always connected, and on which it essentially depends ; and (the 
particular organ at fault being imperceptible) in measures calcu- 
lated to keep the system tranquil ; and, lastly, in determining to 
the surface generally, or helping Nature in that particular mode of 
it exemplified in the part inflamed. 

I believe that, in most cases, the organ or organs particularly 
in fault are easily cognizable, if sufficient pains be taken. That, 
in the majority of cases, any other measures than that especially 
directed to such disorder will be unnecessary ; and the practitioner 
will be presented with so few unsuccessful cases, of those seen at 
a remarkably early period, that, with the exception of those result- 
ing from the imprudence of the patients, he may probably take a 
retrospect of seventeen or eighteen years without finding any but 
a few rare exceptions. I have seen cases of erysipelatoid inflam- 
mation in which the organs apparently most at fault were the sto- 
mach, and again, the kidney. In these cases, emetics, and measures 
soliciting the urinary secretion, would of course, in conformity 
with the principles I have already endeavoured to lay down, be a 
leading feature in your treatment ; always recollecting that, if you 
have reason to suspect that an organ is diseased, your mode of 
acting on it should be an appeal to one or more other organs with 
which it has a community of function or a marked sympathy. 

A summary of the preceding discourse will shew that it in- 
volves the following propositions : 

That erysipelas is an inflammation, the characters of which are, 
in all cases, dependent on a disordered condition of the animal 
oeconomy. 

That this disorder may or may not be more immediately 
dependent on some one disordered function, or on a general dis- 
turbance of the nervous system not discoverably due to any one 
organ. 

That of organs singly considered, the liver seems most fre- 
quently affected. 

That the characteristics of erysipelas demonstrate the coex- 
istence of great excitement, or great action, with deficient power. 

That the treatment essentially consists in the correction of the 
disordered functions on which the disease depends, accompanied 
by measures calculated to determine to the skin. 

That thus its leading feature will be different in different cases. 

That bleeding cannot be freed from the objections which apply 
to it as a remedy, in what are regarded as more healthy infiamma- 



483 



tions ; but that these are, cceteris paribus, of more weight in erysi- 
pelas, as it is characterized by deficient power. 

That the cases in which bleeding has been employed do not 
afford evidence of the benefit of this remedy, which can be 
safely regarded as such w^hen subjected to ordinary inductive 
reasoning ; and (as regards the cases in question) chiefly because 
the remedy has been almost universally employed simultaneously 
with remedies shewn by experience to have gTeater power in the 
removal of erysipelas than bleeding can be shewn to possess. 

That therefore, if bleeding be employed, it should be conducted 
with caution, and be regarded as a measure of very doubtful effi- 
cacy ; as probably unnecessary, and often injurious. 

That bleeding by leeches is frequently useful in erysipelas, in 
that it tends to check local excitement without material diminution 
of power, and thus gives more time for the operation of remedies 
which act more directly on the cause of the malady. 

That all waiters agree as to the general efficacy of remedies 
which demonstrably tend to tranquillize general disturbance, cor- 
rect disordered secretions, and to determine to the surface ; whilst 
they differ without end in regard to blood-letting. 

That erysipelas (those cases which occasionally occur from 
wounds received in dissection) and inflammation of the absorbents 
are essentially the same diseases in their nature ; because many 
cases are exact parallels in all their phenomena : the greater num- 
ber of the facts, however, being merely referred to, as the limits of 
the volume does not allow their insertion. See especially Dr. Butter 
and Mr. Lawrence, op. cit. 

That, although it is not asserted that poison is never absorbed 
in wounds received by dissection, the phenomena by no means 
justify the conclusion that this is otherwise than a very rare occur- 
rence, whether we regard those observed in connection with ery- 
sipelas or inflamed absorbents, or those in connection with what are 
admitted to be poisonous principles, as the bites of venomous in- 
sects, small-pox, &c. 

That there is no real difference in the essential nature of the 
various kinds of erysipelas, implied by the terms erythema, erysi- 
pelas erraticum, phlegmonodes, &c. ; nor in erysipelas from local 
injury or otherwise, ordinarily termed traumatic and idiopathic 
erysipelas respectively. 

That the chief use of incisions seems to be that of shortening 
a process by which Nature is labouring to bring matters to the 



484 



surface with insufficient power ; and that the utility of the bleed- 
ing which may accompany them is extremely doubtful ; since, in 
all inflammations on the surface, these incisions do good, but not 
in any proportion to the bleeding from them ; on the contrary, 
that least blood follow where they are most advantageous and es- 
sential, as in carbuncle. 



485 



DISCOURSE XII. 



ON BOIL, CARBUNCLE, AND ANTHRAX. 

I NEED not, I suppose, again describe a common boil ; but I 
will beg jou to remark that it is a disease whicli is usually very 
painful, red, and attended with much swelling. That we gene- 
rally observe that there is a sort of focus in the inflammation, 
this being most vivid towards the centre : that, around the cir- 
cumference of such central portion, we usually feel the part very 
hard and firm ; and that often beyond this there is a diffused red- 
ness of a somewhat lighter shade. That when it is opened, or 
bursts, the discbarge consists of matter more or less tinged with 
blood, and a small portion of disorganized cellular tissue. That 
though the site occupied by the whole disease may be considerable, 
the destruction of skin is comparatively very small, and, in fact, 
seldom more than is sufficient to allow a free discharge for the 
contained matters. If these characters be increased, we have what 
we term a bad boil ; if they be again augmented, we call the dis- 
ease carbuncle. 

There are, however, one or two points of difference in the phy- 
sical characters of the tw^o cases, to which I will for a moment 
direct your attention, and which will modify a little that view 
which represents carbuncle as only a bad boil, leaving, however, 
their essential characters the same. I w^ill therefore retouch, as 
it were, the sketch of carbuncle which I have already given you in 
a former page. 

Carbuncle sometimes begins in a small inflammatory elevation 
of the skin, a sort of pimple ; more generally, perhaps, it com- 
mences by a sensation of stiffness and uneasiness in some district 
of the skin ; this soon induces the patient to inspect the part, w^hieh 
is, according to my experience, much more frequently on the pos- 
terior surface of the body than elsewhere, and very commonly on 
the back, shoulder, or neck. The patient observes that the part is 
red and tender, and harder than usual. In a day or two, the 



48(> 



redness and hardness increase, and the pain becomes augmented, 
amounting in certain cases to very acute suffering. There is now 
a large patch of redness, sometimes of a scarlet, at others of a 
deeper shade, either crimson, or even with a tint of purple thrown 
over it ; the swelling is not in general very great. The skin too 
has become remarkably dense in its structure, so that it feels very 
firm and close, such as would be compared to brawn, or some kinds 
of leather. He feels feverish and out of order ; the tongue is 
furred ; the pulse excited ; appetite more or less deficient ; his rest 
becomes disturbed : and this is the state in which the surgeon is 
generally consulted. 

If the carbuncle is to proceed, the skin is opened, and generally 
by sloughing : sometimes minute vesicles are seen, and these are 
succeeded by sloughing of the skin, which is thus perforated by a 
a number of holes, giving a cubiform or sievelike surface, which 
occupies the more central portion of the disease. Through these 
apertures there may either be seen issuing, or may be made to 
issue by pressure, a little fluid of a serous kind, mixed sometimes 
with matter or particles of decomposed cellular tissue. The sur- 
face, however, w^hich I thus represented as presenting a number 
of apertures, always sloughs ; and matter, in different cases, 
either tolerably healthy looking, or approximating more or less to 
common pus, is discharged, with blood, matter imperfectly formed, 
and sloughy cellular tissue. 

The quantity of these products thrown off at once, however, is 
usually not very great ; but the discharge takes place gradually, in 
conjunction with the sloughing of the skin and the stratum of cel- 
lular tissue beneath it, to a greater or less depth as the case may 
be. We never obtain that simultaneous discharge of all the results 
of the inflammation in carbuncle, that we so commonly, indeed 
generally, do in boil. The skin, and cellular tissue beneath, seem 
to have undergone a remarkable consolidation, the effect of 
adhesive inflammation ; a character not usually observed in 
boils: nor do we observe, commonly, that extensively diffused 
redness beyond the part which the disease occupies, in any thing 
like the degree in which it so frequently exists in boils. As the 
discharge proceeds, a very large surface is at length left to heal, of 
different depths in different cases ; and the process of repair takes 
place but slowly : it, however, ordinarily progresses, if the case be 
properly treated, and the part ultimately heals ; the patient, for 
the most part, feeling more comfortable than before the occurrence 



487 



of the malady, but not without (m general at least) some sensations 
of debility. 

During the progress of the sloughing, the carbuncle usually 
presents a dirty yellow, sometimes grey surface, with occasionally 
a little blood on it, until the sloughing has ceased ; and a halo, 
more or less regular, of dark-red inflammation surrounding it : the 
parts so occupied affording to the finger a sensation of that hard- 
ness and firmness of structure which I have already mentioned. 

In anthrax, which is merely a severer form of carbuncle, we 
see little more than an extension of these characters. The inflam- 
mation occupies a larger surface ; the suffering is more severe ; the 
surface of a darker red, inclining to purple ; the veins are much 
enlarged, and the slough and other matters discharged are of va- 
rious colours, especially a dirty-grey or slate colour, mixed with a 
tarnished sort of yellow ; the pain is excessive, and the constitu- 
tion exceedingly disturbed. 

The secretions in all of these cases are deranged, but, in severe 
forms of carbuncle, in a very remarkable manner : the tongue is 
dryish or much furred, sometimes both ; the biliary secretion much 
deranged ; no appetite ; and the pulse is greatly excited ; there is 
thirst ; hot and dry skin, though sometimes alternating with perspi- 
ration. If the patient smk, the excitement continues, w^hilst the 
power declines ; the tongue becomes very dark and black ; he 
wanders, and at length sinks into a kind of torpor ; and, in fact, 
dies in all respects like those do who are said to die of typhus 
fever. 

Carbuncles are of different dimensions, from the size of a 
crown-piece to several inches in diameter. In the country, where 
very depraved conditions of the body are sometimes combined 
with considerable power, the inflammation is occasionally very 
severe and extensive. I recollect seeing a stout farmer once, who 
had the whole of one of the nates one mass of slough ; it was a 
very severe case, and he recovered with difiiculty. 

With regard to the constitutional disturbance on which these 
diseases depend, it varies in kind very much in the difl"erent forms, 
and also in different cases where the local disease is of similar 
character. Boils are most common in young and what are called 
healthy subjects ; the more obvious condition being that of reple- 
tion. They are most frequently seen in those who feed heartily, 
without taking the requisite quantity of exercise, and who are 
rather inclined to that fatness and roundness of. form which, when 



488 



more developed, constitute general obesity. Boils may occur 
singly, or there may be two or more, or sev^eral in succession. I 
have seen a few cases where a great many appeared at the same 
time, in various degrees of progress ; but such cases are not very 
common, except now and then, as the sequelee of blisters in pa- 
tients whose skins are unusually susceptible of irritation. Boils 
are not, however, peculiar to the class of persons I have first men- 
tioned. Individuals of a bilious temperament are often very sub- 
ject to them ; and, in fact, they occur more or less frequently with 
almost every variety of disordered condition of the general health. 

Carbuncles, in forms more or less severe, are always connected 
with deranged conditions of the oeconomy, and, in many cases, of 
a serious nature ; sometimes implying organic disease of the 
viscera, but of the liver more commonly perhaps than any other. 
They usually occur in adult, or still more frequently ki advanc- 
ing, life, and in persons who have either lived on too full a diet, or 
who have been hard drinkers. They are not however necessarily, 
I think, connected with such modes of living ; any mode, involving 
habits of any kind which tend to impair the functions of the body, 
such as bad air, unwholesome food, or deficient exercise, seems 
competent to their production. I have seen them in all sorts of 
people ; but I tliink scarcely ever in the severer forms, except in 
those whose former habits had involved excess in some way or 
other as to eating and drinking, habits which are known to impair 
the functions of the chylopoietic viscera, the liver perhaps more 
especially, and to disturb the functions of the nervous system. 
Boils and carbuncles are also not very unfrequent occurrences as 
the sequelae of febrile excitement ; and it would seem that carbun- 
cles are very usual concomitants of the plague. 

All these diseases have this character in common : disorder of 
the general health, and, locally regarded, great excitem-ent, with iu- 
dications of measured power. In all, the inflammation is severe 
in all its characters ; in all, its products are not those of healthy 
inflammation ; and, in all, we observe more or less sloughing ; this 
being, in boil, an invariable accompaniment; in carbuncle, the 
leading feature. In carbuncle, it is interesting to observe the 
thickening and consolidation of structure; which, though imper- 
fectly developed, seems a type of that adhesive process which tends 
to restrict the progress of inflammation to the district required by 
the exigencies of the animal oeconomy ; and, as I have already ob- 
served, these diseases are very eQij)hatic illustrations of that view 



481) 



of inflammation (not induced by the necessity of repairing local 
injury) which regards it as a process by which injurious agents or 
conditions of the oeconomy are got rid of by actions determined to 
the surface of the body. The 

TREATMENT 

of these diseases is similar in principle, though requiring certain 
modifications in its details. In boil, a restricted diet, the avoidance 
of wine and fermented liquors, an efficient aperient, and subsequent 
regulation of the bowels, with a poultice to the part, are all that 
are necessary. In most cases, thus treated, the boil may be left to 
open itself; but now and then it may be necessary to open it, 
when the opening should be a moderately free one, to allow of the 
ready discharge of the thick matter, and the bit of cellular tissue 
which is usually contained in it. Although this be all that is gene- 
rally necessary, patients should be warned against trifling with these 
complaints ; as in some cases, when thus disregarded, the inflam- 
mation may become very severe, disturb the constitution very 
much, or take on even a phlegmonoid erysipelatous character. I 
knew a gentleman who, having an ordinary boil, thought it neces- 
sary so far to pursue his usual habits as to drink a certain number 
of glasses of port wine daily, and make no alteration as to the 
quantity of his diet : under these circumstances, extensive inflam- 
mation of an erysipelatous character took place ; the case was 
severe and tedious ; and left a large sore, which was slow and diffi- 
cult to heal, and requiring much greater privations than any of 
those to which he had at first objected. 

In ordinary cases, however, there is just sufficient constitutional 
disturbance to ensure the required attention. The pain makes rest 
and poultice either essential or agreeable ; the stomach requires 
little food, the appetite being absent or very deficient. I should ob- 
serve to you, that, if a bad boil occurs under circumstances render- 
ing rest inconvenient or impracticable, as sometimes happens in 
travelling, a little pressure, by means of a bandage, very much re- 
lieves the pain during the time that the patient is obliged to be in 
motion. 

If a patient have many boils, the abstraction of ten or twelve 
ounces of blood will often produce a rapid improvement in his con- 
dition ; and this is so well known that I believe the remedy is not 
of very unfrequent adoption. It is, however, always unnecessary, 



490 



if the patient be moderately attentive to the rules prescribed ; and, 
although at one time I used in rare cases and plethoric habits to 
adopt this mode of proceeding, I have long since relinquished it, as 
wholly unnecessary. In regard to carbuncle in sHght cases, with 
the exceptions presently to be mentioned, the treatment will be the 
same as in boil ; but, in severer forms of the disease, we should be - 
a little more active. We generally find the alimentary secretions 
very much disordered ; and those of the liver seldom right. An 
active dose or two of calomel and antimony is here usually neces- 
sary, the bowels having been previously well cleared in the manner 
already recommended in the treatment of inflammation. After 
this, a very gentle saline aperient, with or without a minute dose 
of tartrate of antimony, may be given every four, six, or eight 
hours, according to the case ; and the diet should be gruel and 
toasted bread, and this in moderate quantities ; or, if appetite be 
deficient, gruel only. This plan should be gradually rehnquished 
as the secretions improve, and as the sloughing becomes established. 
The medicine may then be advantageously restricted to a Plum- 
mer's pill every other night, and an aperient or an injection in the 
morning ; but, if the bowels be already regular, and the secretions 
moderately health}^, neither of these measures are necessary. At 
this period, beef-tea, good broth without fat, and a moderate quan- 
tity of bread, should be allowed ; and this gradually increased to a 
more nourishing diet, including a boiled mutton chop daily, until 
the patient is recovered. In some cases, where people have been 
much accustomed to full living, you will find, at the latter period, 
a little porter, or even small quantities of wine, occasionally usefnl ; 
but, in my experience, they are not often necessary : and the same 
observation applies to bark. 

Where the stomach is slow in resuming its wonted appetite, 
there is generally a good reason for it. Nevertheless, in some 
cases, the decoction or infusion of bark, with ten or fifteen drops 
of the dilute nitric or sulphuric acid, seems to accelerate the pa- 
tient's recovery, without being productive of any disadvantage. 
Nay, sometimes the bowels, which may ha^^e required aperients 
before, now act of themselves apparently as the result of an im- 
proving condition, which the bark seems to accelerate. As I have 
before hinted, however, the best strengthener is a plain, moderate, 
and nutritious diet, adjusted to retiring excitability, the state of the 
secretions, and other characters of the individual case. 

The local treatment of carbuncle is very simple. It is of no 



491 



use to try leeching here ; you seldom do any good ; you always 
protract the cure. Nature is trying to bring matters to the surface : 
you should assist her in so doing. I do not say this, if you were 
consulted in regard to a carbuncle at the very earliest period of its 
occurrence ; you would then only see a patch of red, limited in 
extent ; and, in fact, not yet arrived at that stage when the cha- 
racteristic features of the disease are developed. If you catch it 
at this time, check the local excitement by leeches, and endeavour 
to correct the disordered functions which may accompany the case : 
you may remove the cause of the disease, and prevent its further 
progress. We do not, however, usually see things at this period ; but 
when the inflammation is so far developed that sloughing is un- 
avoidable — in this state leeches are of no use. You should make 
a free incision with a sharp knife through the brawny integument 
covering the disease. The cellular tissue and skin are here so much 
consolidated, that nothing short of a thorough division, carried 
quite through the whole skin covering the affected surface and cellular 
tissue, will answer your purpose (in wliich carbuncle differs from 
erysipelas) : and, should the disease be extensive, you may not find 
one sufficient, but be obliged to make two or even more. 

Ordinarily, however, one incision across the whole disease, and 
of the required depth, will answer the purpose. I think the linseed- 
meal poultice should now be applied, as there are usually no ac- 
tions which it is necessary to repress ; and the pain ordinarily sub- 
sides. It is necessary to observe that you will sometimes be called 
to a patient, for the first time, when the carbuncle has been allowed 
to pursue its own course without any assistance from treatment, 
either locally or constitutionally. Under these circumstances, you 
will find a large surface exposed by sloughing, presenting a strange 
party-coloured cavity, surrounded by thickened and indurated in- 
tegument, in a state of greater or less inflammation ; the patient's 
powers very much enfeebled, and in a condition threatening their 
extinction ; so that you have, in fact, nothing to do but support 
strength, for wdiich, nutritious diet, porter, or wine, may be neces- 
sary. 

In such a case, give as little medicine as possible, and regulate 
the bowels by injections or very mild aperients, as manna or castor 
oil. Should the bowels be purged, warm, aromatic cordials, with 
a little hydr. c. creta, will be a proper medicine ; or it may possibly 
be necessary to employ such remedies as the chalk mixture, with 
or without the addition of some narcotic : but you had better rc- 



492 



mit these measures, and especially opiates of any kind, so soon as the 
symptoms which indicated their necessity have subsided. I have 
no experience myself of carbuncle occurring as a consequence of 
fever. The treatment of the carbuncle would be the same, no doubt ; 
and the fact is chiefly interesting, as marking alike the connection 
of the disease with constitutional disturbance, and as emphatically - 
illustrating the general law under which all inflammations (not in- 
stituted for the repair of local injury) occur. 

In carbuncle, generally, the plan which I have mentioned is 
that which I have uniformly seen successful. The only modifica- 
tion of it refers to the comparative conditions of different patients, 
as evidencing greater or less power. I should advise you to pay 
attention to the strength, and either increase the food or continue 
the more sparing diet, as you find debility or excitability take the 
lead, as it were, in the case ; the treatment of which should be a 
well-adjusted mean between excitement and depression : and, as in 
all other inflammations, you will find great benefit from that addi- 
tion to the general measures for the correction of disordered func- 
tion which the detection of the more particular disturbance of any 
organ will suggest to you ; but of this I have already sufficiently 
dwelt, in the general treatment of inflammation. Of bleeding, I 
have not spoken. Most writers mention it as a remedy which may 
be usefiil in some cases. I can only say I never saw a case in 
which I should think of prescribing it ; nor can I conceive it to be 
otherwise than injurious, except when a patient obstinately refuses 
to observe the cautions prescribed to him. 

I give the two following cases ; the one as illustrating the com- 
mon treatment of the disease, and the other as exemplifying those 
extensions of the stimulating plan which are occasionally neces- 
sary. I shall, however, merely give the more essential points, the 
details being tedious and unnecessary. 

1 was requested to see a man of fifty-two years of age, who 
had something the matter with his neck, and who was described as 
being in the most indescribable agony. When I saw him, I found 
that he was a butcher by trade ; that he had been a hard drinker ; 
but he said that, for the last thirteen years, he had been a tempe- 
rate man. I observed the whole of the back of the neck, and the 
inferior boundary of the scalp, occupied by the most malignant- 
looking carbuncle I had ever seen. The colour was deep-red, 
approaching a leaden sort of tint ; large venous trunks were seen 
ramifying in different parts ; the swelling was very extensive ; and 



493 



the skin felt hard and brawny, with the exception of one portion, in 
\vhich, through a few sloughy apertures, there issued a sort of un- 
healthy sanies, of a most horrible foetor, which excoriated the parts 
over which it flowed. The pain was excessive, and so intolerable 
in a recumbent position, that the poor fellow had scarcely laid 
down, night or day, for three days in succession. He said it had 
begun in two small pimples close to each other, which had gradually 
coalesced ; and that, from this time, his sufferings, which had been 
getting worse and worse, had become intolerable. He appeared 
exceedingly depressed in power, although greatly excited ; pulse 
quick, frequent, and small, but rather hard ; tongue white, and 
much coated ; thirst ; alvine secretions greenish. I made three 
long incisions through different parts of the surface thus exten- 
sively affected ; and I ordered a poultice, with some vinegar in it, 
with a view to correct the insupportable foetor of the discharge, 
which was afterwards changed for the chloride of lime. He also 
had his bowels well cleared by graduated doses of calomel and 
jalap ; and he took a drachm of the tincture of hops, with the 
same quantity of hq. antimonii tart, in infusion of calumba, at bed- 
time. — July 24th. I fomid him a little better. The pain was con- 
siderably mitigated, and he had had some refreshing sleep, although 
but for short periods at a time. No appetite ; pulse much the same ; 
bowels are opened, and the excretions improved in appearance. 
To take decoction of bark, with, ten drops of dilute sulphuric acid 
with each dose — 25th. Stools as before ; a good deal of pain at the 
back of the head, where the inflammation is very livid and skin 
very hard. I now extended the three incisions I had already made 
up the occiput ; and, as his bowels still evinced depraved biliary 
secretion, I ordered him to take, at night, five grains of calomel, 
with fifteen grains of jalap. This produced fresh discharges of 
the same kind of disordered secretions, followed by stools of a 
natural colour ; pain relieved ; he now slept tolerably well ; but 
his pulse was small and rapid, and his countenance expressive of 
great anxiety. Sloughing progressing fast ; and discharge of foetid 
and unhealthy matter considerable. — 29th. He is rather better ; 
and some healthy pus is mixed with the discharge from the car- 
buncle. He is, however, very weak. Ordered to increase the 
quantity of porter which he began to take on the 26th ; to omit 
the sulphuric acid ; and to take ten grains of the subcarbonate of 
ammonia with each dose of his bark. His secretions natural, 
and his tongue much cleaner. He now went on very favourably 



494 



until the otli of August, when he unfortunatelj', stumbling, over 
something in his room, had a severe fall, which shook him very 
much. He had continued his bark and ammonia, and was taking 
three glasses of port wine and a pint of porter daily. The neck at 
this time presented a horrid appearance ; for, as a consequence of 
a very deep and wide slough extending across the whole neck, and ^ 
the surrounding swelling, it looked as if the head was half severed 
from the body. The fall threw him back considerably ; the pulse 
sunk ; the separation of the sloughs appeared to be ceasing ; and 
he complains of faintness " coming over him" at intervals, with 
occasional sensations of constriction across his throat and chest. 
He, how^ever, completely rallied from this, and his treatment was 
continued until the sloughs had been nearly thrown off, shewing 
granulating surfaces occupying the situations of those sloughs 
which had separated ; his tongue had become clean ; bowels regu- 
lar ; secretions good ; he was allowed a diet of mutton, wine, and 
porter. Seeing that we could not afford the smallest mistake, I had 
cautioned him, in the most earnest manner, to take nothing but 
what was allowed him ; and, knowing the habits of these people in 
London, I had specially warned him against eels and oysters, 
which, without such special interdiction, they are almost certain to 
indulge in. I found him one morning, however, not so well ; his 
pulse was weaker and more rapid; and he complained of diarrhoea. 
I now found that he had eaten a quantity of oysters the previous 
evening ; and, although we tried e\-erything we could think of, and 
hoped at one period that we had succeeded in arresting the diar- 
rhoea, — yet, after a few hours, it recurred, and sunk him. 

I may observe that the weather was excessively hot, and I 
never saw so bad a case, either as regarded the severity and extent 
of the inflammation and sloughing, or the complete prostration of 
strength and disordered function by which it was accompanied. 
But a great many gentlemen saw the case ; and I believe no one 
had the least doubt at the time, immediately preceding the attack 
of diarrhoea, but that he would recover, or that the imprudence he 
committed was the cause of the diarrhoea which sunk him. I may 
observe here also, that, notwithstanding that we could think of 
little else but supporting his constantly flagging powers from the 
commencement, yet nothing seemed to produce so much permanent 
benefit as the effect on his secretions by the calomel, which the in- 
dication of hepatic disorder suggested, and which his great debility 
had induced me to pndeavour to correct by milder measures. This 



495 



is, to the best of my recollection, the onlj' fatal case of carbuncle 
I ever attended ; but I mention it because I think it instructive. 

AN ORDINARY CASE OF CARBUNCLE. 

Jane Ring, set. about forty, applied at the Dispensary with a 
carbuncle on the posterior surface of the body at the lower part of 
the back. The inflammation occupied a space about the size of 
the palm of the hand. She has had the complaint about a week ; 
and a number of minute ulcerated apertures had already taken 
place, presenting a sort of sieve-like appearance, to the extent of 
about half-a- crown, in the centre of the inflammation. She has 
been in good circumstances, but of late has been somewhat dis- 
tressed ; but, prior to this period, has always " lived well," 

Her bowels are costive, and they are habitually so ; the colour 
of her evacuations, she says, are like " light brandy ;" tongue much 
furred ; urine somewhat scanty and high-coloured ; perspiration 
copious ; appetite deficient : has always had, before, a hearty appe- 
tite. States that she never drinks spirits or beer. Catamenia 
regular up to last April, — it being now August. She says she has 
always had good health, with the exception of costive bowels. 

She was ordered a powder of jalap, containing one grain of 
calomel, to be taken every three hours, until her bowels are tho- 
roughly opened. Two free incisions are made across the carbun- 
cle. She is ordered a moderately nourishing diet ; but not to eat 
animal food for the present. When her bowels were freely opened, 
she was directed to take a wine-glass full of a mixture composed of a 
weak solution of salts with tincture of lavender, in mint water, twice 
a day, to keep them regular. A large linseed-meal poultice is ap- 
plied to the carbuncle. Three days after her admission, the mix- 
ture to be taken only at night. No alteration or addition was 
made to this treatment : the sloughs separated, and the part gradu- 
ally proceeded to heal, without any other measures than a gradual 
return to her ordinary diet. 

I have selected this case, as it occurred in a woman ; carbuncles 
being, in my experience, much more common in men. 

The treatment of carbuncle then is, you see, but the treatment 
of common inflammation, where the disordered function and the 
deficient power are well marked. You evacuate the bowels ; you 



41)6 



solicit a moderate and healthy condition of the secretions ; and 
you direct your attention specially to any one organ that may ap- 
pear particularly at fault ; you assist Nature in her endeavours to 
bring matters to the surface by free incisions ; and you support 
your patient by a light and nutritious diet, in proportion to the 
nature and exigencies of the case ; you keep a vigilant eye on the - 
powers of the oeconomy, and add stimuli if their declension, either 
actual or threatened, renders it necessary. 

I shall devote the rest of this Discourse to, and conclude this 
volume by, a few observations on 

BURNS AND SCALDS. 

When you consider the important functions of the skin, the 
extent, variety, and quickness of its sympathies, you at once per- 
ceive that it is an important organ, and one in which a sudden 
or violent injury would be very likely to disturb the whole oeco- 
nomy in a serious manner ; because you know of no organ in 
which this ever happens without much serious disturbance. Such 
simple considerations would at once lead you to the perception of 
the general character of burns ; they would lead you to expect that, 
in severe forms, they would be highly dangerous. But as you 
have seen that Nature, in carrjdng out the law of inflammation, 
places the majority of these processes on the surface ; and, as you 
perceive that inflammations at or near the surface are those which 
practically prove least dangerous to the animal oeconomy ; so you 
would expect that the infliction of burns, quoad the amount of 
injury, would be less dangerous than similar injury or inflamma- 
tion elsewhere. This is really the case ; for, dangerous as severe 
bums are, on account of the extent and importance of the surface 
affected, yet we know of no organ, except the skin and cellular 
tissue, on which the same amount of injury, as that of which we 
witness the repair in burns, could be inflicted with the smallest 
chance of recovery. 

Indeed, these accidents, and the consequences to which they 
lead, become invested with additional interest when we arrive at 
the perception of true views of inflammation. Accident here fur- 
nishes us with a series of experiments, of which any institution 
by art is impracticable. We see the resources of the oeconomy 



497 



suddenly put in requisition under a great variety of circumstances, 
where the shock given, and the forces required to sustain it, or 
repair the mischief it has occasioned, occur in every conceivable 
degree : and where, in addition to all other variations we have 
that resulting from the injury affecting different districts of the 
surface. Accordingly, burns and scalds are exceedingly interest- 
ing, because very instructive ; they shew^ the harmony and sim- 
plicity of the operations of Nature ; and also that, whatever 
artificial distinctions we may establish between various kinds of 
injury, the law under which they are repaired is the same in all ; 
and that the execution of or interference with that law depends on 
the same conditions, — that is, on the healthy condition of the 
animal oeconomy on the one hand, or on certain disturbances of it 
on the other ; which may either have existed previous to the in- 
fliction of the injury, or which may have been created as the imme- 
diate consequence of such infliction. 

Now, most writers on the subject of burns seem to have re- 
garded, and very properly, the inflammation as the chief circum- 
stance to be kept in view in the treatment ; but still the practice 
wdiich they have superposed on such views has generally indicated 
that their notions w^ere not very clear, and that they were mixed 
up with an impression that these accidents had something peculiar 
about them, either resulting from the agent (heat) w^hich produced 
them, or from other circumstances. Hence, in addition to the 
treatment laid down by the writer — if, indeed, it be not included 
therein, — we find a variety of different remedies mentioned, on the 
authority of others, of apparently the most opposite nature. Thus, 
cold water, heat, preparations of lead, alkaline remedies, soap, va- 
rious ointments, spirituous and stimulating applications, are a few ex- 
amples from the heterogeneous catalogue with which we are usually 
presented. They seldom seem to have been sufficiently impressed 
with the fact, that the real remedy was, after all, the usual process 
of Nature in repairing injury ; and that what little assistance art 
afforded was referrible to one or two simple principles which would 
at once explain the matter. Dr. Kentish, how^ever, is an exception 
to this view of the subject, and seems to have been the first writer 
who, in a practical sense, instituted a more rational treatment for 
severe burns ; although, if I understand him correctly, he does not 
state the true principle on which the treatment is founded ; making 
it, in fact, peculiar in its relation to burns, whilst it proceeds on a 
principle common to other injuries. 

K K 



498 



In the first place, you must dismiss from your minds any thing 
connected with any pecuUar property in heat, and look at a burn 
in regard to its essential characters, which are these : — first, a 
violent and sudden injury inflicted on a very important organ ; and, 
in some cases, requiring very extensive repair. If you restrict 
your views, in the first place, to these essential facts, you will soon 
arrive at the comprehension of the symptoms of bums, and be led 
to their appropriate treatment. As in all other injuries, the effects 
will of course be modified by the degree of injury ; some being so 
slight as to require no treatment at all ; others, again, suggesting 
more or less assistance from art, with a view, however, chiefly of 
relieving suffering; whilst, in a third class, where the injury is 
severe, a patient's life may depend on your affording what little as- 
sistance may be in your power promptly and judiciously, or in 
avoiding interferences which are injurious. 

All kinds of injuries produce all kinds of effects ; in which, 
however, we recognize one property in common — viz. actions 
having more or less tendency to repair them : — first, according to 
the degree of the injury inflicted ; and, secondly, according to the 
state of the body subjected to it. You have seen already that slight 
scratches will sometimes produce very injurious consequences, even 
death itself: you know that, generally, such injuries are of no con- 
sequence. On the other hand, very serious and extensive injuries, 
which may at once destroy certain portions of the body, may be 
repaired by the powers of the oeconomy. Therefore, in all cases 
whatever of injuries ordinarily termed mechanical, or whether we 
extend the notion to those which act, as we say, cbemically — as 
fire, mineral acids, — or whether we include those innumerable and 
intangible influences which result from atmospheric agencies, there 
is this one essential thing to be considered in regard to all of them 
— viz. that an injury to the body, of whatever kind, wliich does 
not at once destroy it, must, in a practical se?ise, be regarded as 
compounded of two forces, very different in their nature perhaps, 
but common as modifying the eflect of such injury. These forces 
are, the injury as characterized by its violence or intensity, and 
the condition of the body as tending to increase or diminish the 
prejudicial consequences of such injury. You will never under- 
stand the phenomena of what are called mechanical or chemical 
injuries, unless you thus couple them with the more enlarged view of 
injurious influences generally which I have endeavoured to explain. 

Now, in burns, and I talk of severe burns, you see a very 



499 



sudden and extensive injury to one of the most important organs 
in the body ; and therefore you will not be surprised that they 
should often prove fatal, because this is very commonly the result 
of all severe injuries to all important organs. Neither will you be 
surprised, if you carry with you the preceding views, that, in regard 
to these accidents, the recovery of the patient will not always have 
a necessary relation to the extent of the injury ; in other words, if 
you see the same extent of injury fatal in one case, and not so in 
another ; and further, if you observe one patient sink under a 
burn much less extensive than some whom you may have seen to 
recover. To illustrate that view of burns which regards their es- 
sential character, as a violent injury to an important part, let us 
see how nearly we can deduce the essential points, in connection 
with these accidents, from others affecting other parts, and where 
the agency of heat is out of the question : and for this purpose it 
matters little what part we select ; because, although the details may 
be different, the nature of the case will be the same. We will sup- 
pose that a man has a violent shake of his brain, by a fall or some 
other injury (concussion, as we call it). What happens ? — why he 
is probably sick, his pulse is very low, his extremities cold ; this 
lasts for a certain time, and then warmth returns, the pulse resumes 
its power, and sensation is restored. We now generally find that a 
contrary state supervenes, — there is excitement ; and we fear that, 
if this be not subdued, inflammation will follow ; and as inflamma- 
tion in the brain is a thing highly dangerous, we endeavour at all 
hazards to prevent its occurrence. 

If we have a wound of the chest or abdomen, similar results occur; 
that is, we have coldness and depression, disordered function, not dis- 
ordered consciousness, perhaps, as in the brain (because the functions 
of the parts are different) , but sickness, or impeded respiration ; then 
we have returning power, with threatening of undue inflammation. 
But, since the latter is necessary in wounds, we do not take it for 
granted that it must necessarily be dangerous ; and therefore we do 
not set to work as if we had determined that formidable inflamma- 
tion must occur ; but we watch the degree of excitement, and act 
accordingly. If such inflammation threaten, we immediately, as 
in the case of the brain, endeavour to subdue it at all hazards, and 
for the same reason — viz. the great danger attending it. 

Now, then, let us take a mechanical injury on the surface of 
the body. A large district of skin is killed by a blow, or it is 
stripped off by a piece of machinery. Here again we have siek- 

K K 2 



500 



ness, coldness, a state of depression ; an injury has been sustained 
of an extent that would destroy life, were it inflicted on the brain, 
lungs, or many other parts. We find here, again, the same set of 
phenomena ; and, after a time, the same reaction taking place : but 
instead of setting violently to work to subdue this reaction, many 
considerations withhold us from such a proceeding. In the first 
place, we perceive an extent of injury requiring repair, which we 
know demands considerable power. We know that this repair 
cannot take place without increased action ; in fact, without inflam- 
mation : and further, we know that iuflammation of the skin is by 
no means so dangerous as it is in the lungs or brain, or many 
other parts ; unless, indeed, very large districts of skin be affected 
at the same time : and if this be the case after an injury involving 
destruction of a large surface, we find the system so depressed, 
that we have seldom much to fear from any exuberance of inflam- 
mation ; and we are further assured that the repair required will 
be risked by any reduction of power. We therefore commence 
the treatment of all the cases which I have mentioned exactly in 
the same manner, or at least on the same principle ; that is, we 
put the patient to bed, and either give him a light cordial or not, 
according to the severity of the case and the depressed condition 
of the system. If the organ injured be one in which we especially 
fear the presence of inflammation — the brain, for example,— we 
withhold the cordial if possible. 

In the case of external injury to the skin by crushing or lacer- 
ation, we place the part in a position which may best protect it 
from motion, friction of bed clothes, or other annoyance ; and we 
place over it some application or other that is of mild, warm tem- 
perature, and which defends it from exposure to the atmosphere : 
the best is a common well-made bread-and-water poultice. This 
we medicate with poppy or other things, according as the pain or 
other symptoms seem to suggest. As the powers return, we aim 
at the prevention of excitement at first by a very mild, rather 
spare diet ; and as we perceive the excitement approaches only 
that degree which always accompanies repair of severe injuries, we 
improve the diet, with a view to support the patient's strength, so 
far as we can, consistently with the avoidance of increased excite- 
ment. Now here, with the exception of some modifications in 
detail, I have been describing the principle on which the treatment 
of burns should be conducted; and yet you see I have not spoken 
of heat as having any thing to do with these accidents. I shall 



501 



hereafter speak of other conditions of the oeconomy, where the 
excitement is continued, and where the injurious influences are 
of a different kind ; and I shall then shew you the harmony of the 
operations of the oeconomy in respect to all injuries whatever. 

As to heat, we know not what the matter of heat is ; but we 
know a great number of the effects it produces ; and that these 
effects are very different, according as it acts on animate or inani- 
mate bodies. In the latter, it separates the particles composing 
them to greater distance (expansion) ; in the former, it excites the 
living actions. Inanimate substances are affected by every variety 
of heat, their temperature being greater or less, as the heat is in- 
creased or diminished. But animals have the extraordinary power 
of preserving a degree of uniformity of temperature independently 
of that of the surrounding atmosphere. The range of this power is 
very different in different creatures, and it is limited in all. In all 
living bodies, however, heat excites the actions of life ; in vege- 
tables as well as animals. They all live faster under a high tem- 
perature ; and if this be very great, the excitement very soon 
destroys vital power, and both vegetables and animals die. We 
see the same effect of heat applied to a part ; in one degree it ex- 
cites gently, and produces phenomena which are attended with 
comfort and increase of power ; in another, it excites so as to 
produce weakness ; in a third, it produces the excitement of in- 
flammation, and this may be so great as to destroy the living 
power of the part and produce sloughing ; and again, the heat may 
be so violent as to produce the same effect on animate as on inani- 
mate substauces, — that is, at once to decompose the part : all of 
which results we observe, not only in regard to burns, but also in 
other kinds of injury, where no heat has been applied. 

Apart from that case in which heat immediately destroys a part, 
blisters and burns often produce exactly the same phenomena, 
according to the case, — either redness, which subsides, or which 
proceeds to vesication, or ulceration, or mortification. Heat, 
therefore, abstractedly considered, is to be regarded as any other 
injurious agent, in that it excites the actions of the part, or de- 
stroys its vitality, according to the intensity of its action : the pro- 
cesses to which it leads being, in a general sense, those calculated 
to repair the mischief it has occasioned, but subject to modifications 
according to the condition of the body to which the injury is ap- 
plied ; as I have before stated. Thus you may have extension of 
inflammation of erysipelatous character beyond the parts ■ injured. 
In some cases this condition will modify these processes so as to 



502 

give them a character very distinct from auy usually observed to 
result from burns. I saw a man the other day who had spilt some 
boiling lead over his hand a few days before : the district affected 
was very trivial, and the slough nearly separated ; but the man 
had pain up the inside of his arm, and inflammation in the ab- 
sorbent glands of his axilla. I knew perfectly well that there 
must be some condition here by which the effects of the burn were 
thus modified : on enquiry, I found that his bowels were costive ; 
that he had considerable tenderness over the liver ; that his tongue 
was furred ; his pulse frequent (110) ; and found also that he was a 
typefounder, and that he said he was much exposed to the fumes 
of lead. Here you see the disordering agency was almost wholly 
due to the condition of body on which the burn had been inflicted, 
and the remedies of course entirely directed to that condition. The 
man was, in fact, just in that condition in which many, and indeed 
most people are, who suffer from wounds received in dissection, or 
from inflamed absorbents from any other cause. This man 
speedily recovered by a few doses of calomel and antimony, a few 
leeches, and the prompt discharge of suppuration in the axilla, by 
an opening made for that purpose. 

Being now sufficiently aware that you are to discard any idea 
of heat producing any peculiar effect, as heat, in these accidents ; 
and that you are merely to regard it, in common with other inju- 
rious influences, as stimulating or destructive, according to cir- 
cumstances (not forgetting that these include the condition of the 
body in which the injury is inflicted) ; you will at once perceive 
what must necessarily be the local and general symptoms of burns, 
according as the injury is trivial, severe, or destructive ; and these 
we will now consider. 

You know, if you take hold of a hot body, as a handle of a 
tea-kettle for example, that, admonished by pain, you get rid of it 
as quickly as possible ; and that the results are an acute pain and 
redness of the part, which, after half an hour or so, will subside. 
That, if the part be subjected to the heat of boiling water, it will, 
according to circumstances, either produce extensive redness and 
pain for a longer period, or it will blister the part ; and that this 
may speedily get well, and the cuticle so bhstered be thrown off ; 
or it may be followed by ulceration of the surface, or even super- 
ficial mortification. That, if the heat applied be greater, such as 
that of melted metal, sloughing is almost certain to follow ; and, 
if this heat be increased in temperature, or be applied for a longer 
period, the surface of the body is at once charred and decomposed, 



503 



becoming black ; and that all this must be separated bj sloughing 
before the repair can take place by granulation in the usual manner. 

We will now, then, consider the symptoms of burns where the 
heat applied is great, the surface extensive. In such cases, the 
patient complains of great pain and heat in the parts affected hy 
the accident ; but, in almost all cases, there is also a general sense 
of cold . This varies in different cases : in some, there being gene- 
ral chilliness ; though, for the most part, absolute and severe shiver- 
ing ; in many examples, as severe as that which characterizes the 
first stages of ague. You see here the immediate depressing effect 
of severe injury on the skin ; and that the shivering is more marked 
than we perceive it to be on injuries of other organs. This state is suc- 
ceeded by excitement, the pulse becoming accelerated from TOO to 
130 ; thirst ; restlessness ; and, in short, the ordinary phenomena 
of fever. The bowels appear generally to require some solicita- 
tion, the tendency appearing to be to costiveness. I seldom find 
that this is mentioned as a characteristic symptom. If the patients 
die, they may sink under the immediate shock of the severe injury ; 
they may go on for three or four days until suppuration becomes 
established, or they may die about the eighth or ninth day, during 
the earlier stages of the separation of the sloughs. This is the ex- 
perience of Dr. Kentish ; and it accords with my own, although 
I have not seen a great number of these accidents, considering that 
I have not been unfavourably circumstanced. After a time the 
excitement subsides, except that degree which we almost always 
observe in. the repair of injury, and which is chiefly characterized 
by a sustained frequency of pulse, somewhat more than natural. 
If the patient die, the excitement is followed by embarrassed res- 
piration, torpor, perhaps delirium, and he dies comatose. I should 
have mentioned that some affection of the urinary secretion is usu- 
ally observed in burns. 

Dr. Kentish has given very good instructions as to the treat- 
ment of these accidents ; and which, in a practical sense, seem to 
proceed on correct principles. I think, however. Dr. Kentish, in a 
very natural disgust with the former treatment of burns, which pro- 
ceeded on no principle at all, or on one evidently false, seems rather 
to have fallen into an opposite error ; and, in combating that prac- 
tice which would at once employ sedative applications, appears to 
continue those of a stimulating kind rather longer than there is 
any occasion for them. Neither do I think that the analogy that 
Dr. Kentish draws, between burnt and frost-bitten parts, is quite 



504 



the right view of the case ; so far as relates to the gradual bringing 
back of parts to their natural condition. A great deal of the ob- 
scurity and difference of opinion on the subject of burns evidently 
results from too much having been attributed to art and too little 
to nature ; for, as Nature is the chief agent in all, so it necessarily 
has happened that bums of the same description have done well 
under very different and opposite modes of treatment. The body 
suffers a severe injury : the main question is, whether its powers 
are equal to sustain or repair it ? If they be equal, the probability 
is, that none of the apphcations, usually employed in burns, will 
render them otherwise : if they be unequal, it is equally probable 
that all measures will fail in rendering them otherwise. 

In very severe injuries, however, it is reasonable to suppose 
that a very little interference may in the one case throw the 
balance in favor of the injury, and in another in favor of the con- 
stitution ; and therefore the treatment of burns really, in a practical 
sense, becomes interesting only as regards the severer cases ; since, 
in trivial forms, the constant recovery from these accidents, under 
all sorts of treatment, strongly leads to the conclusion that neither 
of them exerted any very potential influence as to the ultimate re- 
sult of the case. For, whilst this conclusion is perfectly recon- 
eileable with what we know of the powers of Nature, it is equally 
so with the facts presented to us in that variety of local treatment 
which we perceive to have been adopted by different writers. In 
such cases (I mean light cases) the only thing appears to be to re- 
move impediments in the way of Nature ; and we find this best 
accomplished by general repose and the correction of any disorder 
of ftmction ; because we know that disordered function weakens 
the powers of the general oeconom}'. Another point in Hght cases 
(as well as in severe burns) consists in diminishing the sufferings 
of the patient ; for w^e may thus facilitate and accelerate that 
favorable termination which we do not abstractedly control. In 
se7}ere burns, however, experience 'proves that the calls on the 
powers of the oeconomy are in most cases very nearly equal, in 
some superior, to those powers : and, as we can never determine 
before hand which of the two it is to be, so it becomes a very im- 
portant consideration what we are to do ; because, where the power 
and the agenda are in pretty equal counterpoise, it follows that a 
very little increase of the one, or interference with the other, will 
render the case unsuccessful. In investigating this question, I con- 
fess that there appears to me only one mode by which we can aus- 



505 



piciously seek the information we require : and tliat is, by regarding 
those circumstances which apply to all severe injuries in common, 
where the injury requires repair ; because, as the laws of Nature 
are simple, we shall most probably arrive thereby at the real inter- 
pretation of her wants ; and thus be led to the simplest mode of 
assisting in their supply. In all cases of severe mjuries, we per- 
ceive that the system receives a shock, which is accompanied or 
characterized by depression of power. In all cases, we perceive 
this depression followed by excitement. If the body be in good 
order, this excitement is moderate ; if otherwise, it is apt to be ex- 
cessive. If excessive, we naturally endeavour to moderate it ; and 
the true mode of doing this is the same in all cases : that is, by 
removing the cause of this excess. N"ow this we find (in confor- 
mity with the laws and phenomena of infl.ammation) to be either a 
general absence of natural power, from some inscrutable condition 
of the nervous system ; which may either result from the severity 
of the injury, from causes unknown, or from some condition of 
some of the organs of the body : the former we caimot recall ; the 
second we are ignorant of ; the third we may or may not be able 
to discover. Hence, in all cases, when quiet, warmth, and, if 
necessary, stimuli, shall have been followed by recovery from the 
immediate depression of severe injury, we next moderate the ex- 
cessive excitement. In some cases, as in the brain, lungs, &c. 
where the injury, as regards the repair required, is trivial, we en- 
deavour to arrest it by any means we can : and here we may em- 
ploy many with impunity at least, — which we cannot do where the 
case involves that sustained increase of action necessary to re- 
pair. In these eases, we are exceedingly anxious to avoid anything 
that tends to decrease power ; because we know that power is 
necessary : therefore, such a measure as bleeding, in burns, is highly 
doubtful, as probably prejudicial ; and therefore we should refrain 
from bleeding on the occurrence of excitement, for the same reason 
that we should in the case of a compound fracture. You know 
that this remedy has been occasionally employed in both ; but I 
hardly conceive that it can ever be proper. Of compound frac- 
ture, however, I cannot now speak ; and, in bums, bleeding is now 
scarcely ever, I beheve, employed. The proper mode of allajdng 
undue excitement is by ministering to those conditions of the body 
which favor its excess : this will practically include a general atten- 
tion to the various organs, with an especial reference to any which 
may appear particularly disturbed ; the evacuation and regTilation 



506 



of the bowels, and the ensuring a regularity of the biliary and di- 
gestive functions ; and, in burns, the state of the kidney should 
also receive our particular attention. Then, as regards the parts 
injured, why you place them in the most comfortable position you 
can, you apply comfortable warmth ; you defend the parts from the 
contact of air ; the warmth during the stage of depression being of 
all things most desirable. When the excitement begins, you make 
no alteration, except that, if your measures in relieving the de- 
pression involved any stimulating agent, common sense suggests its 
abandonment. We then address ourselves to the excitement, by 
the measures already mentioned ; and, this having been reduced, 
we then support the patient's powers by plain and nutritious diet, 
carried so far as we can do it without inducing excitement ; and, 
as patients are generally weakened by the joint effect of the injury 
and the excitement following it, and as they are now taking, of 
course, no exercise, we find, practically, that this diet is of a 
measured kind, implying a sustained moderation as to quantity ; 
that this varies in different cases, seldom amounting to the full diet 
of health. 

I have thus endeavoured to shew you that the treatment of all 
serious injuries is, in principle, the same ; and thus to impress, 
that burns, therefore, are to be treated on one common to other in- 
juries : and I think you will perceive that, with some little modifi- 
cation, it is in harmony with that treatment which Dr. Kentish 
recommends, who has written, as it appears to me, far more scien- 
tifically on this subject than any other author with whose writings 
I am acquainted. 

The only difference is, that Dr. Kentish extends the stimulating 
plan beyond that period at which the patient recovers from depres- 
sion, and apparently with a good practical result, though not, I 
think, on a correct principle. Dr. Kentish thought that the treat- 
ment of burns should be, as I have observed, conducted on the 
same principle as frost-bitten parts ; and as, when a part is frozen, 
the practice is to restore its equilibrium by the gradual application 
of snow, cold water, &c. until it was at length subjected to the 
ordinary temperature, so Dr. Kentish begins by stimulating 
strongly ; then he reduces his stimuli ; and at length relinquishes 
them altogether, the stimulus being then only that of a moderately 
light and nutritious diet. Now, in the first step, Dr. Kentish ar- 
rives by a different route, as it were, at the plan employed on the 
immediate infliction of any severe injury on a vital organ, increas- 



507 



ing the stimulation in a way which we dare not do when the lungs 
or brain, for example, are affected ; and for a good reason ; because, 
in the lungs and brain, we are afraid of any subsequent inflamma- 
tion : whereas, in burns, we cannot do without considerable and 
sustained increase of action, since the repair depends on it. Then, 
in the second stage, instead of withdrawing his stimuli, as the ex- 
citement occurs, at once, he does this gradually ; whilst, for the 
reasons already mentioned, when vital organs are affected, we with- 
hold them at once. The third stage, though it implies (quoad Dr. 
Kentish's previous stimulating measure) a reduced diet, is practi- 
cally much the same as that employed, at the same period, in any 
other severe injury which demands extensive repair, as in compound 
fracture. 

Indeed, as compound fracture is much more analogous to a 
burn, than injury or concussion of vital organs is, in the extent of 
repair required ; so is the treatment much more closely allied to 
Dr. Kentish's treatment of burns, in that chary reduction of power 
which characterizes the management of such cases, when com- 
pared with our treatment of injuries to organs, where, whilst in- 
flammation is more dangerous, the accident seldom implies the 
necessity of any material repair of structure. 

In burns, therefore, the treatment is, in principle, essentially the 
same as in all severe injuries, the characteristic feature being a 
most careful husbanding of the powers of the oeconomy, rousing 
them until excitement be produced ; and then gradually withdraw- 
ing all adventitious stimuli, except those which give substantial 
power, as nutritious food, and medicines which either confer power 
by regulating the various functions, or which seem to have this 
property by sustaining the powers of the stomach without exciting 
the system, in the way that bark appears to do. Before I speak of 
the general treatment of burns, I may observe that Dr. Kentish 
found it necessary to give calomel in certain cases ; and that he 
regulated the bowels by aperients and injections. He says that the 
case was often accelerated, during the healing process, by occasional 
purgatives. He also employs tonics of bark occasionally, changing 
these for medicines of the same class. 

Supposing, then, a severe burn to have been inflicted, the 
knowledge of the principles on which you should proceed, as dis- 
tinguished from an acquaintance with a catalogue of various and 
opposite remedies, will at once furnish you with the plan of treat- 
ment under almost any circumstances ; and this, of course, is a 



508 



very material thing in all cases of accidents, which occur in situa- 
tions and under circumstances in which you may or may not have 
particular applications at hand. In the first place, you remove all 
clothes or covering from the burnt surface, which should be done 
carefully, and with as much gentleness as possible ; you then (I 
am only speaking of severe cases) put your patient in bed. You 
can always procure alcohol in some form or other, as common gin, 
or some other spirit ; and with this, previously warmed, you can 
gently sponge the burnt parts. If you have it at hand, you can 
then lay over them light dressings of lint or linen, thinly spread 
with yellow basilicon ; this will be a gentle stimulus to the parts, 
and will prevent the dressings sticking, when you wish to renew 
them, or replace them by some application which you may prefer, 
and which, in the interval, you may have been able to obtain. If 
your patient be very depressed, you may give him a light cordial, 
such as the aromatic confection, with cinnamon- water, and a draclmi 
or two of spirit in it ; or, should this not be at hand, a little spirit 
and water may be substituted, in equal parts, and given w^arm. If 
the pain be very severe, thirty or fort}' drops of laudanum may be 
added with advantage. Dr. Kentish first bathes the burnt parts 
with spirit of wine and camphor, and then lays over them dressings 
spread with yellow basilicon, rubbed down with sufficient spirit of 
turpentine to render the ointment thus formed of the consistence of 
a liniment, which he applied warm. I should advise you to apply 
this dressing if you can procure it, in preference to any other, for 
many reasons : first, because, as a first dressing, it is evidently in 
harmony with the principle on which that depression immediately 
consequent on severe injuries should be treated ; secondly, because 
Dr. Kentish, whose experience in those severe cases which happen 
to miners from explosions of hydrogen gas, shews it to be a good 
application ; and, thirdly, because the turpentine may produce great 
benefit in a way which I do not perceive mentioned by Dr. Kentish, 
and which refers to certain principles of treatment, in relation to 
the sympathies of organs which I endeavoured to explain in the 
book on that subject, the Unity of the Body, &c. 

We know that turpentine has a pow^erful effect on the kidney ; 
we know that the sy mpathy between the skin and kidney is mani- 
fested in certain alternations of secretion, and phenomena already 
mentioned in former pages of this work ; and that both organs are 
engaged in throwing off certain matters from the body. You have 
seen that the urinary secretion, in severe burns, is generally af- 



509 



fected ; usually high-coloured. Now, ii> these cases, the skin has 
a large portion of its structure destroyed ; we therefore cannot rea- 
sonably suppose but that the functions of the remaining part must 
be disturbed. Besides this, it has plenty of duty in assisting in the 
required repair ; and therefore, if we could relieve it in any way, by 
promoting the action of organs having ever so general a community 
of function with it, and whose powers are not disturbed by any 
direct injury, we should, as diminishing the ordinary duty of the 
skin, probably increase its power in performing those which acci- 
dent has rendered necessary. Many reasons render it extremely 
probable that the turpentine exerts a beneficial influence in this 
maimer ; since neither the application of stimulants nor turpentine 
to burns commenced with Dr. Kentish ; nevertheless, we observe 
a rapidity of progress in his cases, especially when we recollect 
their severe nature, which, so far as I know, we do not witness 
when cases are treated in other modes. To shew you how extra- 
ordinary an influence certain excitement of the kidney may have 
on affections of the skin, I will tell you one example where the 
remedy employed, though not turpentine, was prescribed on a 
principle to which I conceive a portion, at least, of its beneficial 
operation in burns is to be ascribed. I have mentioned the case 
in a book already quoted ; but it is so valuable that I make no 
apology for repeating it here. 

A woman came to the Dispensary with a large superficial ulce- 
ration of the left leg, completely occupying the whole limb from 
the knee to the ancle. She was desired to rest, poultice, and attend 
to her diet and bowels. I was talking of sympathy to two gentle- 
men who were sitting with me at the Dispensary, when the next 
patient happened to be this old woman, eet. seventy-two ; and, in 
explaining how they should examine cases, I said — " There now is 
a ease, which, from the large surface affected, and from what you 
know of burns, would suggest the probability that some of the 
parts which sympathize with the skin will here be well marked. 
Now,'"' said I, " first try her alimentary canal." Her tongue was 
not healthy, nor much otherwise ; appetite good ; and bowels regu- 
lar. We then enquired as to the kidney. We found that she 
made a very small quantity of water indeed, and that, generally, 
very thick ; but every now and then she said she made a consider- 
able quantity of pale urine. I ordered her to omit all the medi- 
cine, and take simply a diuretic (the nitrate of potash with squills). 
The next time I saw the woman, you may judge my surprise at 



510 



fiuding that tlie whole of this immense surface had healed in one 
week ; the kiduej acting naturally. Soon after this, the leg became 
mieasj, when it was immediately relieved by the same measure. 
The other parts of the case are related in the book to which I have 
referred. I say, then, use Dr. Kentish's dressing, if it be at hand ; 
if not, content yourself in the adoption of the principle, so far as 
the means in your possession allow you. As soon as the immedi- 
ate disturbance, consequent on the accident, has a little abated, 
direct your attention to the bow^els : but here, again, be vigilant 
over the powers of your patient ; let the discharges from the 
bowels be full, free, and satisfactory, without being too profuse or 
accompanied by unnecessary excitement. Small doses of jalap 
and rhubarb, with a little cinnamon or other aromatic — or, if this 
be not at hand, castor oil — will be the proper remedies ; and these 
should be assisted by an efficient injection of warm w^ater. 

I should not, myself, continue the stimulating dressings so long 
as Dr. Kentish recommends, unless I saw that there was an ab- 
sence of any commencement of the processes necessary to repair. 
Dr. Kentish says, that after he discontinues them, if the reparative 
actions become slow or cease, touching the living parts with spi- 
rituous lotions will renew the reparative actions. The treatment 
should now be one which supports the system without exciting it, 
combined with great attention to the secretions, and simple dres- 
sings to the parts* ; these being renewed about once every twenty- 
four hours. Various modifications as to diet, medicine, and mea- 
sures directed to particular organs, will be suggested in different 
cases, and which of course must rest on the discretion of the prac- 
titioner, the principles being the same in all. With regard to the 
prognosis in burns, severe cases are to be regarded as dangerous 
accidents ; nevertheless, under proper treatment, they often do well 
under apparently very untoward circumstances. In children, they 
are more dangerous even than in the adult ; but I cannot speak 
very safely from my own experience ; since, at the time I saw most 
of these accidents (I mean severe burns), the cases were certainly 
not properly treated, in many instances. 

In all lighter cases, and in these I include alike scalds and 
bums, which occupy pretty large districts of skin — such as the 
greater part of a limb, for example, — you may generally predict a 

* Spermaceti ointment, ung. lapid. calamin. or yeUow basilicon with lard, in 
equal parts, or lard only ; but the quantity should be very small, and spread on 
fine lint or linen. 



5J1 



favorable result : the cure may be very speedy or protracted, ac- 
cording to the powers of the patient and the more or less judicious 
character of the treatment. This should be essentially that of 
inflammation of the skin. If the reparative process progresses, your 
duty will be restricted to some simple dressing (of which a bread- 
and- water poultice is the best), and attention to the general func- 
tions of the body. Do not be snipping or otherwise interfering 
with the vesication ; this is officious and unnecessary. 

Burns and other extensive injuries of the skin sometimes pro- 
gress ver}' favourably to a certain point; there being a large sur- 
face covered, perhaps with tolerably healthy gi'anulations, and a 
certain extent having already healed. In such cases the power is 
deficient, but seldom, I think, from simple exhaustion of nervous 
effort ; there is always some condition of some organ on which it 
depends, in the absence of proper treatment. If the patient have 
improper food or bad air, these may the competent explanations. 
Dr. Kentish seems practically to have found occasional purges 
beneficial in these cases ; but the particular remedy will be of 
course different, according to the circumstances. If a patient be 
in a hospital under these circumstances, the sooner he is dis- 
charged or made an out-patient the better. In some cases, a 
little increase of diet, with slightly stimulant applications to the 
sore, will be sufficient : but, in general, fresh air and attention to 
the general or certain individual functions of the body, as sug- 
gested by a more particular scrutiny than is generally bestowed, 
will be the most successful treatment : and, as in all cases where 
you wish to husband power, should the appeal to any organ, 
suggested as necessary, require the employment of a powerful 
medicine, you will obtain advantage by endeavours to excite it 
intermediately through some organ with which it may sympathize ; 
provided this excitement involves agencies of a more simple or 
less disturbing kind. Burns are very often presented at the Dis- 
pensary where the processes are going on slowly or unkindly, and 
where there is a sort of irritative erysipelatous inflammation sur- 
rounding the part : in such cases you will find almost always some 
impaired function or other ; and that, whilst you are correcting 
this, the application of some leeches on the inflamed surface will 
contribute to accelerate the reparative processes. 

One very important thing, in relation to all reparative processes 
whatever, I should mention : that in adjusting the quantity of sup- 
port (and especially the quantity of stimuli, as wine or beer, should 



512 



tliat be necessary), you should ascertain well the previous habits 
of jour patient ; for, if they have been characterized by the free 
use of stimuli, the constitution may require an extent of allowance 
which in ordinary cases would be highly prejudicial. In old per- 
sons also, we are obliged to be very careful, in all cases of local in- 
jury, not to allow the powers to sink too low, by suspiciously 
watching any real indication of their decline ; and, though sti- 
mulants should never be given otherwise than with a sustained 
recollection of their exciting, as contradistinguished from their 
strengthening properties, yet in such persons a liberality in this 
respect is advantageous, which in younger subjects would be in- 
jurious. In Dr. Kentish's cases, the benefit apparently attending 
the continued allowance of beer or wine may probably have had 
more reference to the previous habits of his patients than to any 
necessity arising abstractedly from the nature of the injury ; since, 
in all cases whatever, requiring repair, experience impresses nothing 
more forcibly than this — that whilst any thing which gives strength 
is of the greatest utilitj', yet it is a necessary condition that it 
only produces a very measured excitement. The most nutritious 
diet, therefore, with, the addition of wine or porter, according to 
circumstances, consistently with the avoidance of excitement, seems 
the point of excellence ; and the most unequivocal evidence of this 
is an increased power of pulse with a diminution of frequency. 

The contraction which T have formerly remarked as chaj^ac- 
terizing the cicatrization of all wounds, when multiplied, as it were, 
by the vast surface involved in the healing of extensive bums, 
becomes a source of great inconvenience. Thus, we find parts so 
contracted as to interfere with their functions, limiting the motions 
of joints, as in the arm, or drawing dovvn the face, and everting 
the lower lip ; and thus subjecting the patient to an annoying drib- 
bling of saliva, imperfect articulation, and great deformity. The 
prevention of these occurrences consists in placing the parts in 
their natural position, and retaining them there by bandages, splints, 
or other means appropriate to the situation, not only until the parts 
have healed, but for a considerable period afterwards. We are, 
however, often called upon to relieve these cases where we have not 
had the treatment of the burn ; and it becomes requisite to set^the 
parts free, and preserve them, by the measures already mentioned, 
in their natural position for the time stated. 

In some cases, a simple division of the cicatrix is all that is 
required, so far as the knife is concerned : in other examples, the 



513 



parts are so disposed that this simple division is impracticable. 
Mr. Earle has proposed to dissect out the cicatrix, and then preserve 
parts in their natural position, to which thej are thus restored : 
and I believe that the experience of that gentleman renders him 
satisfied with the measure. In all cases, however, where a simple 
division of the cicatrix will enable us to restore the limb to a na- 
tural position, the severer measure of dissecting out the cicatrix 
will probably be unnecessary : in illustration of which, I may re- 
late a case. I was called to relieve a contraction in a boy's arm, 
which was bent to nearly a right angle, by a contraction consequent 
on the healing of an extensive burn ; the cicatrix extended from 
the lower part of the arm down to the thumb, which it had bent 
inw^ards towards the wrist, so as to render it nearly useless. 

As the removal of the whole cicatrix would involve of (course very 
severe suffering, I was desirous of trying what might be effected 
by a simple division. Selecting therefore a portion of the cicatrix 
that appeared most concerned in the contraction, which w^as oppo- 
site the bend of the arm, I ran a sharp-pointed knife deep through 
the contracted integuments, and, cutting outwards, divided the ci- 
catrix. The arm became immediately freed from confinement, but 
in a much less degree than I had anticipated ; and, on feeling the 
wound, I discovered that the cellular tissue had become thickened 
and increased to a still greater depth than that included in the in- 
cision. I was proceeding therefore to divide or remove this to 
such extent as might be necessary, and in such a situation, safe as 
regarded the vessels, when the boy became so desperate and un- 
manageable, that it was found impossible to proceed without fur- 
ther assistance. I therefore placed the arm in a splint, adapted to 
the utmost extension which the division of the cicatrix had ren- 
dered practicable, and directed it to be retained steadily in that 
position. I w^as much pleased to find, on the removal of the splint, 
that the arm could now be extended to a still greater degree than 
the curve of the splint allowed. Another splint was therefore im- 
mediately made, adapted to this increased extension ; and, as this 
became still greater, another splint was provided, and so on until 
the limb became perfectly straight, when it was placed in a straight 
splint, and kept there in the manner I have already recommended. 
I find, from Mr. Earle, that, even when the cicatrix is dissected 
out, the contraction is not always immediately remedied ; but that, 
by bringing the edges together, or approximating them as nearly 

L L 



514 



as may be convenient, and keeping the parts in position, tlie de- 
sired results gradually take place. 

The older surgeons, however, were acquainted, it appears, with 
similar and scarcely less efficacious modes of proceeding. Wiseman 
(p. 442), gives the following case. " A boy came out of the coun- 
try v^ith all the fingers of his right hand close contracted. I cut 
the cicatrix of each finger, and caused a rowl of wood to be placed 
under his crooked fingers, which being carried with bars to the 
inward part of his wrist, and fastened by screws, thrust the roud 
gradually forward, till it had borne all the fingers before it, and 
by a compleat extension, restored them to their former liberty." He 
adds, " The wrysts and other joynts would he subject to the same 
inconveniences if they were not prevented by the knowing Artist, 
without whose help the best medicaments signifie little." 

I believe I have now stated all that I consider necessary in re- 
gard to burns; and a summary of the subject will shew you that — 

Burns are to be regarded as severe injuries to an important organ, 
requiring, in many cases, extensive repair, and consequently con- 
siderable and sustained power. 

That this repair necessarily requires inflammation ; which, 
again, in different cases, involves effusion, ulceration, sloughing, 
granulation, cicatrization, &c., according to the nature of the 
injury. 

That inflammation may be healthy and reparative, or other- 
wise ; and that, if otherwise, the remedies for its correction are 
just those adopted to other unhealthy inflammations ; that leeches 
may be necessary : but that, considering the repair required, and the 
power necessary, general bleeding can seldom be either necessary 
or proper. 

That the first efleets of extensive burns are analogous to those 
accompanying any severe injury of any important organ, — that 
is, a state of depressed power : — that this is succeeded by excite- 
ment, and in burns very rapidly. 

That if patients die w^ith burns, they die at periods, with sym- 
ptoms and under circumstances strikingly analogous to those which 
precede death under any other species of severe injury. 

That the treatment consists, first in restoring the powers from 
the immediately depressing effects of the injury, and then gra- 
dually withdrawing that artificial mode of stimulation as the sub- 
sidence of such disturbance leaves the ceconomy in a condition fit 
for conducting the necessary repairs. 



515 



That in the process of this, the snstentation or increase of 
power depends on principles aUke applicable to all cases of exten- 
sive repair : that it consists chiefly in plain nutritious diet, and in 
the correction of any disturbed function ; which disturbance always 
impairs power. That, in certain cases, this will include the addi- 
tion of porter or wine, according to the severity of the case and 
the peculiarities of the patient. 

That the local treatment proceeds in harmony with the gene- 
ral : — 1st, one of a stimulating character ; 2ndly, the reduction of 
this to such applications as sooth the surface by protecting it from 
exposure, and render it otherwise comfortable, — that, as in regard to 
the constitution, so in regard to the injured parts, the resumption 
of stimuli may be, in certain cases, necessary. 

That slight burns seldom require much interference, the in- 
flammation being seldom more than is sufficient for the repair 
required : that in these, however, in certain cases, unhealthy in- 
flammation is set up, which must be also met by the means recom- 
mended generally in unhealthy examples of this process. 

That, in all local injuries, we must regard the injurious in- 
fluence directed against the general safety of the oeconomy as 
practically compounded of two forces — the absolute intensity of 
the injury, and the particular condition of the body at the period 
of its infliction. 

That this may sometimes give, even to trifling burns, charac- 
ters by no means necessarily arising from such accidents, as in the 
example of inflamed absorbents, &c. quoted. 

That the principle of correcting or relieving functions, by ap- 
peals to the sympathies existing between different organs, is to be 
held in view as very important in burns, both in relation to the 
nature of the organ injured, and as correcting those conditions on 
which the occasionally protracted healing of such cases appears to 
depend. 

And, lastly, that the phenomena of burns, as giving us exam- 
ples of recovery from injuries of a nature and extent which would 
be elsewhere certainly destructive, afford a beautiful illustration of 
the preventive tendency of the law of inflammation, which deter- 
mines that process to the cellular tissue and the skin, representing 
the exterior investments of the body. 



L L 2 



APPENDIX, 

CONTAINING A FEW 

GENERAL AND ELEMENTARY REMARKS 

ON THE 

STRUCTURE AND FUNCTIONS OF THE BODY, 

DESIGNED TO 

ASSIST THE STUDENT OR UNPROFESSIONAL READER. 



519 



APPENDIX. 



In the schools, the student generally commences the study of 
Anatomy and Surgery together. In order, however, that he should 
fully avail himself of the most elementary parts of his surgical 
lessons, it is necessary that he should have a general idea of the 
body. Without this, also, the unprofessional reader can scarcely 
understand the most simple propositions in regard to medical sci- 
ence ; or, at all events, without a labour that is very unnecessary. 
These considerations have induced me to subjoin a few remarks, of 
a very elementary nature, on the structure and functions of the 
body. 

In the first place,, you should understand how the body is built 
up and maintained in repair ; and, in explaining this, the first 
thing necessary will be to enquire into the source of the material 
employed. Now, all animals have the power of converting vari- 
ous substances to the nature of their own bodies. The power is 
various in its extent and kind ; but no animal is absolutely without 
it. It is sometimes called assimilation and digestion ; you will see 
the meaning of these terms immediately. The conversion of food 
into the various structures of the body implies the healthy perform- 
ance of very many functions. First, the food is converted into 
chyle ; this is the business of the digestive organs : then it is con- 
veyed into the general mass of the blood ; this is done by the ab- 
sorbents. It afterwards undergoes certain changes, by being passed 
through the lungs ; and is finally distributed to all parts of the 
body by the arteries, the minute ramifications of which fabricate 
and deposit the material required. 

The whole of these processes constitute assimilation, strictly so 
called ; the first step is digestion. The parts directly engaged in 
this important function are the alimentary canal, liver, and perhaps 



520 



spleen ; the pancreas or sweet-bread ; and some other salivary 
glands. In all animals, digestion has tliis in common ; that the 
matter to be digested is brought in contact with some surface of the 
animal, either internal or external ; and the first step is the con- 
version of such matter into a more or less fluid form ; in fact, a 
solution of it. So far all animals are alike ; but in many other 
points they differ. Some animals can digest almost all kinds of 
food ; some only vegetable ; some only animal matter ; some, 
again, can only digest a limited number of articles from these 
kingdoms of nature ; and there are many who appear to live on a 
single article. Then, again, the processes to which the food is 
subjected, previous to its digestion proper (solution), differ. In 
some animals, the food is simply brought in contact with the 
digesting surface. In others, it is simply divided in the first place ; 
and, in a third kind, it is ground down into a much comminuted 
state before it is presented to the stomach. In many animals, this 
is managed, as you know, by the teeth placed in the mouth ; in 
others, it is effected either by a strong muscular stomachy or by 
certain processes in it answering the purposes of teeth, as in the giz- 
zard of birds, and stomach of the lobster, respectively. These differ- 
ences in animals are found to be connected with corresponding 
differences in the form and complexity of their digestive organs. 
Some animals are little else but stomach ; some have the stomach 
in the form of a single sac ; some have it representing several 
cavities ; then, again, some possess organs in addition to the diges- 
tive apparatus ; and we observe a gradual rise, as it were, into the 
more complex and highly developed digestive structures in man. 
Yet there is nothing sudden, nothing abrupt, in the chain formed 
by the different variations in structure ; all is harmonious ; every 
link represents a gradual, and only a gradual, change ; the obvious 
mechanism is different ; the plan diversified : but the principle is 
alike ; the result the same ; viz. the conversion of food to the na- 
ture of the individual. But the adaptation of plan has an intelli- 
gible reference to the kind of food on which the animal lives ; so 
that, in a vast multitude of larger animals, a comparative anato- 
mist can tell, from any one part of the digestive apparatus, the 
teeth inclusive, on what the animal was destined to live. Animals 
that live on vegetable substances have one plan in their digestive 
apparatus ; those which live on animal food, another ; and those 
w^hich digest both, a digestive apparatus that partakes of the cha- 
racter of both plans of organization. I need not say that this is 



521 



the case in man ; and I now proceed to give you a sketch of his 
digestion. 

The food, having first nsuall j undergone some preparation, and 
having been masticated by the teeth, is conveyed into the stomach, 
where it undergoes a sokition, the surface being first softened, and so 
on from without inwards, until the several portions are dissolved ; as 
the solution* proceeds, it is gradually urged forwards into the next 
portion of the canal, w^hich we call the duodenum ; there being be- 
tween these tv^'O parts — that is, the stomach and duodenum— a con- 
tracted portion, which is called the pylorus. In the duodenum, 
the digested aliment is seen adhering to all sides of the bowel in 
the form of a whitish cream-liket fluid ; but, as we trace the canal 
onwards, we find the contents assume more or less of a yellow 
colour. Now it is into this duodenum that the liver pours the 
bile, or yellow, soapy fluid ; and the pancreas or sweet- bread also 
pours an aqueous secretion, allied in its properties to saliva. The 
digested aliment is passed onwards by a gentle worm-like, undula- 
tory motion of the intestines, until it reaches a spot w^here the 
canal suddenly changes its character, becoming much larger ; this 
larger part being provided with a valve, which allows the contents 
of the bowels to pass onwards from the smaller intestines into the 
larger, but which prevents any movement in a contrary direction. 
This is, in fact, the commencement of the large intestine, which, 
pursuing a course upwards on the right side, crosses over the 
abdomen ; then descending on the left side, it makes a sort of turn 
over the edge of the pelvis, and then proceeds downwards to the 
anus, where it terminates. 

Now, although the whole canal from the mouth is continuous, 
we speak of different parts of it by different names, calling the 
whole the alimentary canal. This canal, then, may be regarded as 



* The notion that the food is first converted into an homogeneous substance, 
called chyme, is not a true representation of the matter. In all the cases which 
I have examined, the solution takes place in the manner described in the text. 
This I have formerly observed in a book on " The Various Forms of Porrigo, &c." 
The secretion of the stomach to which we proximately attribute the solution of the 
food, is a bland, transparent fluid, having, during digestion, a slightly acid pro- 
perty ; but nothing in its chemical composition explains its wonderful power. 

t This is the chyle, which is a fluid very analogous to blood, but wanting the 
colour. It separates like blood into a coagulated portion and some serum ; and 
contains fibrin, albumen, sugar, and some oily and saline matters. 



522 



m;i.de up of the stomucli and iutestiues ; the intestines oi" the 
small and large. Thirst, then, after the gullet, we have the capacioiis 
bag, the stomach ; then the small intestines ; then the large. That 
portion of the small intestine next the stomach is called the duo- 
denum ; to the remainder, we apply the names jejunum and ilium. 
There is no natural division between these last ; the small intes- 
tines have, in their interior, certain folds, which are calculated to 
impede the progress of the nutritious fluid, and yet not to prevent 
it ; and they are called by the somewhat whimsical name of val- 
vulee conniventes, as if they connived at the passage of the matters 
they were calculated to detain : as the nutritious fluid becomes 
less, these valves become less numerous ; and it is to this portion 
of the small intestines that we give the name of ilium ; the upper 
portion, that is, nearer the stomach, being the jejimum. The large 
intestines we divide into the colon and rectum. In the colon, w^e 
speak of the following parts : that part in which the small intestine 
terminates is somewhat more capacious than the rest, and is of a 
bag-like form ; it has also a little, long, blind tube going from it, 
pervious towards the cavity of the bowel, but closed at the other 
end. This is called the vermiform or w^orm-like appendix of this 
bag, which we call the head of the colon ; and w^e add the term 
blind from this worm-like appendix ; so that, technically, the name 
of this commencement of the large intestines is the caecum caput 
coli ; and we generally call it the caecum. The large intestine now 
proceeds upw^ards on the right side (the ascending colon) ; then 
crosses over the abdomen, forming a sort of arch (the arch of the 
colon) ; and then descends on the left side (the descending colon), 
where, turning over the brim of the pelvis (sigmoid flexure of the 
colon), it ends in a curved bowel (improperly, therefore, called the 
rectum), which terminates at the anus. 

Now, from the whole surface of the alimentary canal, the nu- 
tritious fluid is absorbed, and carried by vessels, called absorbents, 
from smaller into larger trunks ; which, ultimately terminating in 
veins near the heart, thus pour their contents into the general mass 
of blood, W'here we w^ill leave it for the moment, only recollecting 
that it was poured into veins ; mixed, therefore, with venous blood. 

We will now say a word or two about other organs, v/hich 1 
mentioned as pouring their contents into that part of the alimentary 
canal which w^e called the duodenum. One of them was the liver, 
the largest organ of the body. A healthy liver presents much the 
same general appearance as the liver of other animals ; it is placed 



523 



on the right side, and extends a considerable distance across the 
centre of the upper part of the abdomen, even to the left side of 
it. In man, and in many other animals, it pours its secretion (the 
bile), ^r^^, into a sort of little reservoir (the gall bladder), from 
which it is gradually expelled into the duodenum, as I have men- 
tioned. In the same situation, the pancreas or sweet-bread also 
pours its fluid. Deep in the left side of the upper part of the abdomen, 
you find the spleen (the melt of animals), which does not pour any 
fluid into the alimentary canal, that we know of, and the use of 
which is entirely unknown. It returns its blood, however, by a large 
vein, which, uniting with another large vein returning the blood from 
the bowels and other parts, forms a vein larger than either, which 
proceeds to the liver, in the substance of which it ramifies, and fi^om 
which we believe the bile to be secreted. This large vein is the 
vena portse of the liver ; and its communication with the splenic 
vein, and with that returning the blood from the bowels and other 
parts, readily enables us to understand how embarrassment in the 
circulation of the liver may afl"ect the spleen or the bowels ; of 
which latter many diseases of the rectum, as piles of different kinds, 
are examples ; and which exemplify what is so often seen — viz. the 
seat of disease being in one place, its cause in another. 

It is necessary to observe that no food we can take is wholly 
nutritious ; there is more or less in all kinds which cannot be made 
use of, and this it is the especial function of the large intestines to 
discharge. When the food reaches the csecum it undergoes a re- 
markable change, both in colour and still more in odour ; and many 
circumstances induce us to believe that some little nutriment may 
still be obtained from it ; for that the interior surface of the large 
intestines is capable of absorbing nutritious matter, we learn from 
the occasional support derived from intestinal injections thrown into 
these bowels, when we cannot give food by the stomach. The ali- 
mentary contents, however, when they reach the large intestines, are 
now moved on more quickly until they reach the lower bowel, 
through which they are ultimately discharged. This bowel is fur- 
nished with a circular muscle at its extremity, which, whilst it 
prevents the alimentary contents from passing inconveniently, still 
readily yields when they have accumulated so as to excite a desire 
for their discharge. 

t have said that the nutritious fluid is absorbed from the whole 
suriace of the alimentary canal. The vessels which execute this 
oflice, from the white colour of the chyle, are sometimes called the 



lacteals. Now tliese absorbing vessels exist in every part of the 
bod V : thev are constantly carrying off old material from the parts 
which they occupy, and carrying it into the circulation, whence it 
is ejected by some one of the excretions. In the alimentary canal, 
the absorbents take up a vast quantity of new material ; as it were, a 
fresh supply : all absorbents carry their contents first to certain 
bodies which we call glands (popularly kernels), which glands seem 
to examine, as it were, and perhaps impress some change on the 
matter brought to them. Now, a great many of these are placed in 
a fold of membrane (which I shall presently speak of ), and which 
secures the small intestines in their situation, and which we call the 
mesentery : we therefore speak of the mesenteric glands ; and 
although we cannot be said to know the precise nature of the change 
wrought by absorbent glands on the fluids brought to them, before 
they are allowed to pass onwards through these glands to the cir- 
culation, yet the consequences of disease of these glands shews 
their functions to be important ; for if the mesenteric glands be much 
diseased, patients generally die — the appetite being craving, but the 
body emaciated ; because, even if digestion take place, the digested 
fluid either cannot get through the diseased glands of the mesentery 
to the circulation, or cannot get those changes impressed on it 
which are necessary to its becoming ser\dceable to the economy. 
I shall suppose, however, that myriads of absorbing vessels, which 
terminate in the villous interior surface of the intestines, have taken 
up the chyle, have conveyed it to the glands, and these have 
allowed it to pass onwards by other absorbents, which, terminating 
in larger and larger trunks, ultimately discharge their contents into the 
veins near the heart, and thus mix the newly manufactured blood, 
or chyle, with the general mass of the circulation. It is now carried 
onwards to the right side of the heart, vrith the general mass of the 
venous blood. 

And now we have to consider certain changes which are to be 
effected in the blood, of which the chyle thus forms a part ; and 
this leads us to consider what is called the circulation of the blood, 
and the changes wrought in this fluid by respiration. 



525 



CIRCULATION. 

The circulation of the blood accomplishes primarily two objects: 
first, the supply of all parts with a fluid essential to their life ; and, 
secondly, the return of any quantity which is not required, or 
which has undergone changes unfitting it for the purposes of life, to 
certain parts (the lungs), where it, and any additional fluids which 
may have been mixed with it, undergo those changes which refit it 
for the nourishment of the body — for being again distributed. The 
principal organ in its distribution is the heart ; the pipes through 
which it is carried are the arteries ; those by which it is returned 
are the veins, which ultimately pour it again into the heart, but 
not into the same chamber (ventricle) whence it was distributed ; 
for this chamber, to which it is returned by the veins, contrac ts 
and urges it forward to the lungs, when, having undergone the 
change required, it is now sent back to the other chamber of the 
heart (the distributing chamber), where it is urged forwards to all 
parts as before. 

We thus see that we have two chambers, as it were, in the 
heart, which only communicate through the tubes which convey 
the blood from the one to the lungs, and return it to the other i'rom 
these bodies. These chambers, however, are divided into two com- 
partments, called auricles and ventricles, and, as in animals, they 
are placed right and left, and somewhat inchned towards these sides 
in men, we speak of the right and left sides of the heart. Now it is 
to the right side that the blood is returned, and this we will call the 
venous, or right side ; and it is from the left, that, having undergone 
the changes in the lungs which make it arterial, it is distributed ; the 
point of which we feel beating on the left side, between the sixth and 
seventh ribs, and which we will therefore call the left or arterial side. 

You will now, I think, be able to follow me in tracing the course 
of the blood more particularly. As it is a sort of circle, it matters 
not where we begin ; so let that be from the point of propulsion to 
all parts of the body, that point being the left or arterial ventricle 
of the heart. This ventricle, on receiving the blood, contracts on 
it, and urges it first into a large pipe or artery, the aorta ; this giving 
olf a number of branches, these divide and extend in every direction, 
and convey the blood to all parts of the body. When the blood 
arrives at the part which it is to nourish, the arteries subdivide 
until they become exceedingly minute, and then they gradually 



52C) 

become veins, which veins, at first also exceedingly minute, gra- 
dually coalesce ; and this continuing as they progress towards the 
heart, they continue to form fewer and larger pipes, until at last 
only two remain, and by these the blood is poured — returned, in 
fact — to the right or venous side of the heart. This side has, as I 
said, a divided chamber; the division which the blood first reaches 
is called the right auricle, and, by contracting, urges forwards the 
blood into the ventricle ; from this it is again urged forwards to the 
lungs, by a vessel which, dividing and subdividing, carries it 
through the lungs ; these ultimate subdivisions again begin to form 
larger trunks, and ultimately return it by four pipes* into the left 
or arterial side of the heart ; but first to the chamber called the left 
auricle, which (as on the right side), contracting, sends the blood 
into the left ventricle, which is the point where we started, and 
whence, as I have said, it is distributed to all parts of the body. 

Now, when the blood leaves this point, it is, as I have stated, 
arterial, and of a bright scarlet colour ; but when it has reached the 
part which it is to nourish, it gradually loses this colour ; for no 
sooner do w^e find it in a vein, than we see that it has become dark 
red or purple. This colour it retains until it has been sent by the 
right side of the heart through the lungs, where it again becomes 
scarlet; in which state it reaches the left side of the heart, wdiich is 
again to distribute it to the body. 

When we speak of the circulation of the blood, we refer generally 
to the distribution of the blood from one side of the heart (the left) 
and its return by the veins to the right side. When we speak of the 
pulmonary circulation, we mean merely that transmission of the 
blood from the right side of the heart through the lungs, and its 
return to the left, or distributing chambers, on that side of this organ. 
Now, a great point in the distribution of the blood is, that the 
distribution be equal ; and this not only as regards the momentum 
with which it is to move in different parts, but also in the quantity 
supplied to them. But when we use the term equal, we do not 
mean that it should be exactly alike, either in the quantity supplied 
or in the momentum or velocity with which it moves ; on the con- 
trary, there is every thing, short of absolute demonstration, to 
convince us that the circulation is different in different parts, in both 
these points — that is to say, that some parts have more blood than 



* Pulmonary veins. 



527 



others, and that the blood circulates in different parts with different 
velocities ; and farther it maj he observed, that in disease we can 
distinguish that the blood souietinies flows more or less quicklj' in 
different parts. That the equality or adjustment of the actual con- 
ditions of parts in this respect is important, we infer from the fact 
that obvious disturbance of it produces disorder of some kind or 
other, and from the fact also, that this disturbance seems an dtment^ 
at least, in all disorders. The problem involved is verj complex, 
being in fact the distribution of a fluid bj an organ through pipes, 
the branches of one main pipe, to parts differently distanced from 
the propelling power ; and notwithstanding thjit the pipes reach all 
parts, yet w^itli differences as to supply, and with different velocities. 
Now we cannot entirely explain how this is accomplished : in no 
knoivn hydraulic machine would it be possible ; yet we can see pro- 
visions calculated to effect the object, although we cannot imitate 
them. In the first place, all the distributing pipes are elastic ; and, 
secondly, they have a power of contracting on their contents beyond 
that allowed by the sphere of tLeir elasticity. And again, we observe 
that, in the angles at which the different distributing pipes branch 
off one from the other, they present every conceivable diver- 
sity. We also observe another very curious circumstance — viz. 
that no part depends on any one source for its supply ; that 
in all cases one, and in many several, pipes might be obliterated 
without the part in question being deprived of its supply of 
blood. Now, we believe that these circumstances, especially the 
elasticity, the contractile power, and the angle at which arteries 
are given off, are the means through which the adjustment of the 
circulation is effected. We see the contractile power of the arte- 
ries greatest as they become most distant from the propelling 
power (the heart), near which power their greatest elasticity seems 
serviceable in protecting the vessel from injury, under circumstances 
(not unfrequent) of unnatural force in the propulsive power of this 
organ. 

Hydraulic influences, as resulting from the different angles of 
the arteries, have been discarded by high authority as explaining the 
distribution of the blood ; but when we know'that the progress of 
a fluid through tubes is influenced by this circumstance, and that 
in the arteries these angles present endless diversities, it is difficult 
to believe that they do not exert some influence. It is true that in 
the pipes whence we draw our hydraulic notions, we have neither 



52S 



elasticity, nor that contractility wliicli is superadded to tlie arte- 
riesj yet all the arteries have these properties, and, ceteris paribus, 
it seems difficult to explain how these hydraulic influences should 
not still be exerted*. Besides, although we can by no means explain 
the various angles of arteries on hydraulic principles, yet we see 
something in harmony with them too. For example, when blood 
is to be conveyed to a distant part, we find that the arteries divide 
at acute angles, as in the brachial, femoral, and their primary sub- 
divisions, affording hydraulic facilities to distant parts ; whereas, 
w^ien the blood reaches the part, we usually observe hydraulic im- 
pediments, so to speak, in the distribution and subdivision of the 
vessels. i\gain, when the parts supplied are near the heart, where 
the force is acting most efficiently, we find the vessels going off at 
right angles, or nearly so ; thus affording, so to speak, hydraulic 
impediments, as we see in the intercostal arteries. 

x\nother very curious thing, and which points, I think, very 
strongly to hydraulic influences, is the intervention of arches in 
different parts, from the concavity or convexity of which the sup- 
plying arteries branch off. The arch of the aorta is by no means 
to me satisfactorily explained by the mere circumstance of the heart 
being placed superiorly to many of the parts to be supplied ; for this 
does not explain the arches which we see in the circulation of 
other parts, as the hands and feet. Then, as regards the brain, the 
hydraulic influence is admitted ; for, as the blood approaches the 
brain, we see in many animals provisions obviously calculated to 
moderate the current of the blood before it enters this organ, either 
in the tortuous course of the vessels, O'" in their division and reunion ; 
and whilst this is most remarkable in animals whose heads are 
more in a line with the heart, it is still more remarkable in animals 
which graze than in those w^hich have not the head so constantly 
favouring, by gravitation, the blood's momentum. Thus the impedi- 
ment afforded by the tortuous course of the cerebral artery in man, 
is greater in the plexus found in the lion, and still greater in that 
found in some herbivorous animals. How^ever, I just throw out 
these hints as matters of interest; my object here is not physiolo- 



* The connection of the distribution of water to the earth and its inhabitants 
with the ordinary laws of attraction and gravitation, — and its proximate depend- 
ance in many cases on the known laws of hydraulics, — are very interesting and 
demonstrable ; and there is no reason to believe that the distribution of a fluid in 
an animal body necessarily requires a different law. 



529 



gical, further than as impressing by such considerations a few verj^ 
elementary facts in regard to the actions of the body. 

We have reason to believe that the veins also possess some 
power of contraction, and we know that they are slightly elastic : 
we must, however, refer to the former property the exceedingly 
varying size of the vessels. We also know that the superficial 
veins have valves, which allow the blood to move towards the 
heart, but which oppose it in the contrary direction ; the action of 
muscles also we know to help the progress of the blood through 
these vessels. It has been suggested, that during respiration a 
vacuum is formed in the right side of the heart (into which you 
will recollect the blood returns), favoring the venous circulation. 
It is probable that all these causes have some effect ; so that the 
distributing forces may be, first, the force of the heart; second, the 
elasticity and contractile power of the arteries ; third, hydraulic 
arrangements in the course and angles of the arteries : the returning 
forces ; the via a tergo of the heart and arteries ; the elasticity and 
modified contractile power of the veins, their valves and muscular 
action ; and, probably, hydraulic arrangements here also. The idea 
that you should have of an artery is an elastic pipe, which remains 
open when you make a section of it, having also, in the living body, 
a power of contraction and dilatation, and -carrying scarlet blood 
from the heart to all parts of the body ; a vein being a tube which, 
unless it be large, collapses when a section is made of it, having 
therefore little elasticity and little contractile power, but possess- 
ing a small degree of both, and carrying (returning) purple blood 
from all parts to the heart. 

Notwithstanding the foregoing, which I believe is the general 
idea of the forces by which the circulation is carried on, I cannot 
say that it appears to me satisfactory. The pressure of the heart's 
action on a long column of blood, filling a number of tubes, would 
not only be sufficient to impel the blood through them, but even to 
injure the tubes, were not these tubes elastic on the one hand, and the 
blood free to move on the other ; for, though the power of the heart 
be small, yet when it is multiplied by the surface of the arteries, 
in conformity with the law by which fluids press equally in all direc- 
tions, it must be enormous, and even dangerous, were it not for the 
provisions which I have mentioned. I should therefore myself be 
rather disposed to refer the contractility of the smaller arteries to 
the offices of growth, nutrition, and deposition generally, than as 
being at all necessary to help the circulation. There seems, indeed, 

M M 



530 



to me no subject more promising either to liydranlics or physiology 
than the study of the circulation, with regard to the principles of 
hydraulics. It is full of interest, at all events ; and I cannot help 
thinking that physiology and hydraulics might each be made, by 
such an investigation, to improve the other. 

It may be right to make a few remarks now on the fluid thus cir- 
culated (the blood). The blood is the material by which all parts 
are nourished and sustained therefore it must be distributed to all 
parts, as you have already seen : and for this purpose its fluidity is, 
of course, well adapted. You have seen that its colour is red ; 
purplish -red in the veins, scarlet in the arteries ; but in many ani- 
mals the colour is absent ; and in some again, red blood is only 
distributed to certain organs : even in man, there are many parts 
not supplied with red blood. 

The blood, when out of the body, spontaneously separates into 
certain parts : lirst, there is a clot (the crassamentum) ; secondly, 
a fluid, greater or less in quantity in different cases (the serum). 
In the clot, or cressamentum, we again distinguish the fibrin, or 
greater mass, and the colouring matter ; and as this is found, when 
placed on the field of a microscope, to consist of globules, so we 
speak of the clot as commonly consisting of this fibrin and red 
globules. We find also, that if the serum be subjected to moderate 
heat, it also presents tw^o parts, the greater portion coagulating, and 
forming what we call the albumen (as is the white of an egg), and 
another portion, which may be pressed out of this in a fluid state, 
to which we give the name of the " serosity." 

I may observe that the coagulum which forms spontaneously, 
and which we call the crassamentum, or clot, forms more slowly in 
some cases than others ; and that where this happens slowly, the 
red globules (the heaviest part of the blood), sinking deeper into 
the clot, leaves the surface of a lightish yellow colour : this is what 
we call the buffy coat. This is supposed to characterize the appear- 
ance of blood in inflammation ; but we cannot safely adopt this 
conclusion, because the appearance is olten absent where inflamma- 
tion is certainly present, and ol'ten present without inflammation : 
it seems to have more relation to excitement than to inflammation. 
With regard to the composition of the blood, you will find some 
dilTerences of opinion in chemists, both as to matters contained in 
it, and also in their relative quantities ; but the subject forms an 
interesting chapter in almost every w^ork on Chemistry. 



531 



The following is one of the analyses given by Dr. Turner in his 
work on Chemistry : — from a paper by M. Lecanu. 

Water 780-145 

Fibrin 2-100 

Colouring matter 133-000 

Albumen 65-090 

Chrystalline fatty matter 2-430 

Oily matter 1-310 

Extractive matter, soluble in water and alcohol 1-790 

Albumen, combined with soda 1-265 

Chloride of sodium 

of potassium # 

Carbonates of potash and soda > 8-370 

Sulphates i 

Phosphates ^ 

Carbonates of lime and magnesia ^ 

Phosphates of lime,' magnesia, and iron. . . . >- 2-100 

Peroxide of iron .5 

Loss . 2-400 



1000 000 



There is a great deal to be said on this or any other analysis ; 
but my object is only to give you a general idea of the subject. 
The red globules are said to be of different shapes im different 
animals ; but in all microscopical observations the sources of fal- 
lacy are such, that we seldom find observers agree in the results of 
their observations. I chiefly wish you to understand, that it is from 
this fluid that the various parts of the body are built up, and that 
the necessary changes by which the blood becomes converted into 
bone, muscles, and the various structures, are wrought by the 
minute vessels of the part. The blood undergoes certain appre- 
ciable changes in some diseases ; but it is highly probable, from all 
the facts, that there are man;^ others not detectable by any chemical 
mode of proceeding at present known. The fact I have just 
adverted to, however, should be borne in mind; because, if it be 
true th-at parts are built up by the conjoined agency of certain vital 
properties of the blood and the actions of the minute vessels, you 
will at once perceive that no change of structure can take place 
without some alteration in the properties of the blood or the action 

M M 2 



532 



of these vessels. In such cases, it is possible that the fault may be 
sometimes attributable to the material, in others to the workmen, 
as Mr. Hunter calls the minute arteries ; and, in examining these 
points, investigation of the material would naturally lead us to 
enquire of the manufacturers of it. 

Now, these are the digestive organs, primarily ; the various 
glands of the body, through which the absorbents carry the fluid, 
so prepared, to the general mass of blood; and lastly, the lungs, 
in which the blood is subjected to air — respiration. But as all 
these processes are subservient again to a superior power, as 
it were, so the fault may be primarily there : this power is re- 
presented by the nervous system, on which I shall add a few re- 
marks presently. 

The changes which the venous blood undergoes, in order to fit it 
for distribution by the arteries, is effected by respiration ; in which 
the drawing in of the air, or inspiration, produces a great change 
both in the blood and the air so inspired. The statements in regard 
to some points of the details of this process are so conflicting, that 
I had better merely mention here that the air drawn in loses a 
portion of its oxygen, and that this is replaced by carbonic acid, 
and this in pretty equal quantities, so that the blood becomes 
changed from venous to arterial : the obvious physical change, and 
one, probably, abstractedly unimportant, being a change from 
purple red to scarlet. That this change is consequent on exposure 
to air, that this exposure is necessary to all animals, we know ; but 
it is certain that the vital powers play some part in the process, 
which cannot be explained by any chemical investigation. 

The changes thus produced in the blood are, as I have said, 
chiefly the result of respiration ; but there is the strongest reason for 
beheving that the skin contributes to them so far as regards this 
absorption of oxygen, and the throwing off of carbon ; so that we 
really breathe partly by the skin. Dogs perspire very little, apparently; 
but we always see the lungs very hard at work during exertion, 
which we do not notice in so marked a manner in animals who 
perspire freely, as horses. I may observe that the heat of an 
animal, and the power it possesses of maintaining uniformity of 
temperature, have a general relation to the development of the 
lungs and the quantity of oxygen consumed by them ; and, as in 
combustion, oxygen disappears aud forms an oxide, which in res- 
piration is represented by the carbonic acid, so the heat of animals 
has been supposed to be thus generated. Many very serious ditfi- 



533 



culties lie in the way of this tempting conchision, and which merely 
conduct us to this point — that life plan's some part in the whole 
process, to which all the other phenomena are subservient. 

You have seen now how the blood is made, first, bj the fluid 
elaborated from the food hy the digestive organs ; how this is 
carried by the absorbing vessels, through certain glands, to the 
general mass of venous blood ; how it is ejected from the right side 
of the heart through the lungs, undergoing here the final change 
which fits it for distribution to the body, by the left side of the 
heart, to which it is then conveyed. Now you must understand 
that absorbents^ exist in every part, and as the minute arteries lay 
down new material, so the absorbents of every part remove the old ; 
the body is thus always undergoiug mutation of its parts, new 
materials being constantly deposited, and the old ones removed. 
When these two sets of vessels act in harmony, the natural form of 
all parts and the general symmetry of the body are preserved ; but 
if this harmony be destroyed, parts undergo either increase or 
diminution of volume. If the absorbents are more active than the 
blood-vessels, more is taken away than is deposited, and parts be- 
come smaller ; if, on the other hand, their activity be small, or that 
of the blood-vessels too great, their increase of bulk is the conse- 
quence. In various diseases we see exemplifications of this : if the 
material be redundant, and the person otherwise healthy, then the 
material is laid up, as it were, in the cellular tissue, in the form of 
fat. But sometimes diseased actions, as we call them, accompany 
this too abundant deposition, and then such deposition may repre- 
sent a structure similar to some others in the body, or altogether 
different from any, forming tumours, as we call them. 

When parts are killed by injury, or perish under the influence 
of some action of disease, they are thrown off, by the absorbents 
removing the parts wliich unite them to the living structures. In 
this way, these vessels have functions of the highest importance ; 
and the remembrance of the few facts which I have mentioned is 
of great moment in the treatment of disease. The absorbents 
carry the matters absorbed into the venous circulation ; but first, 
as I have said, through certain bodies or glands, which seem to act 
like sentinels, and examine and probably produce some change in 
the fluids brought to them, before they allow them to pass on 
through other absorbents again to the blood. There seems reason 
for believing that, in some cases, the matter is of a very injurious 
character ; since, whether in consequence of anything in the matter 



534 



itself, or of merely diseased excitement coutinned along the ab- 
sorbent to the gland, we find that irritation, inflammation, and 
suppuration, are set up in the gland, and apparently with the effect 
of arresting the progress (either of morbific matter or of simple 
irritation) onwards to the absorbents nearer the circulation. The 
idea that you should have of an absorbent, is a fine, membranous, 
transparent vessel, having a power of contracting on its contents, 
and the function carrying a variety of matters ; some nutritious, as 
the chyle ; some that are to be ultimately expelled from the body 
as no longer of use to it. 

Now the organs by which all matters which are either useless 
or injurious to the body are expelled, are the bowels, kidney, skin, 
and lungs. Of the bowels and lungs I have already spoken ; and 
of the skin I have said that it contributes to the separation of 
carbon. The kidney is largely supplied by blood, from which it 
separates a variety of matters, the retention of which would be 
injurious. This it does by means of the secretion of urine ; and 
we learn the exceeding importance of this, as well as other func- 
tions which throw off matters which are either directly injurious 
or no longer useful, by what happens from their retention. The 
urinary organs secrete a peculiar fluid (the urine), in which the 
matters, destined to be ejected from the body through this channel, 
are dissolved in various states of combination. The quality of 
even healthy urine will of course, therefore, vary much at different 
times, and according to the variety of duty imposed on the kidney, 
and especially by the digestive organs ; for, if they do not do their 
duty in any way, the kidney is almost certain to have more to do ; 
if matters taken up from the alimentary canal be not pure, the kid- 
ney and skin must separate them ; so, if the bowels do not throw 
off the innutritions residue of digestion, we invariably find the 
urine loaded. 

The following is an analysis of healthy urine, by Berzelius : A 
thousand parts contain of 



Water 933-00 

Urea 30-10 

Uric acid 1-00 

Free lactic acid, lactate of ammonia, and animal 

matter not separable from them. 17-14 

Mucus of the bladder 0-32 



535 



Sulphate of potash 3-71 

of soda , 3-16 

Phosphate of soda 2-94 

of ammonia r65 

Miiriate of soda 4-45 

of ammonia i'50 

Earthy matters, with a trace of fiuate of lime. . 1*00 

Silicious earth o 0 03 



Various departures from this and every other analysis are ob- 
served, and yet there may be no disease. In other cases, disor- 
dered action in the kidney, consequent on the imposition of excess 
of duty, or other causes, leads to unhealthy secretion, giving rise 
to most tormenting maladies, as gravel and stone, in connection 
with which, the peculiarities of urine must be more particularly 
considered than 1 can do in this place. The liver is also an organ 
which contributes to carry out matters from the body, the retention 
of which would be injurious. The function of the liver, however, 
is very imperfectly understood, the secretion of bile being perhaps 
merely one of the functions of this vast organ. This secretion, 
however, evidently throws off something which would be injurious 
if retained ; and contributes very materially to more than one pro- 
cess connected with the digestion of the food : for we find that 
digestion itself is performed very imperfectly, if the bile be defi- 
cient ; and that the bowels seldom, in this case, throw off the 
fseciilent remains of digestion as they should do. The bile is a 
yellowish, soapy, somewhat tenacious sort of fluid, which is found 
to consist of a number of salts, as phosphates and muriates of 
soda, in solution with water ; and certain peculiar principles, to 
which the names of cholesterine, asparagin, picromel, are given 
respectively ; but the analyses are so different that I have not 
thought it useful to transcribe any of them. 

The organs which I have mentioned are those which make the 
blood, which distribute it, and which carry off either the old mate- 
rials of the body, or any other matters no longer required. We 
will now then take a cursory view of the principal structures built 
up from the blood by means of the minute arteries ; and, for the 
purposes here intended, it will be sufficient to mention bone, liga- 
ment, tendon, muscle, what are called the membranes of the body, 
and the cellular tissue. 

The bones are composed chiefly of animal matter, iji which is 



536 



deposited an abundance of phosphate of lime, to which the}' owe 
their strength and firmness. Sometimes small additions of carbo- 
nate, and even sulphate, of lime may be detected ; but, in the human 
bone, phosphate of lime is the chief solidifying material. The 
skeletons of some animals (shell-fish, for example) are almost 
wholly made ,up of carbonate of lime. The animal matter in 
bone is chiefly gelatine, and therefore soluble in hot water : which 
happens when we make soup from bones of beef or mutton ; there 
being in them, however, a small portion of albumen. 

The bones form what we call the skeleton ; and the general 
use which it senses is to contribute to the protection of parts, and 
to assist the powers of motion, by the addition of convenient 
mechanism. As examples of the protection it affords, I may men- 
tion the brain, and the heart and lungs, in each of which cases it 
forms a sort of box for the protection of the parts which it encloses, 
resisting forces of considerable violence, and provided with means 
for diminishing the effects of concussion; as jarring. To this the 
peculiar saw-like edges of the bones of the cranium probably, in a 
small degree, contribute : but the provision is still more remark- 
able in the chest, where it is necessary for other purposes. The 
chest is formed by a portion of the spine behind, by the sternum 
in front, and by the ribs on either side ; but the cartilages or gristle, 
interposed between the joints of the ribs with the spine, and 
still more the long pieces of gristle which connect the ribs with the 
breast bone, give to the whole chest a remarkable elasticity ; the 
effect of which is, that when, as in drawing in the breath, the chest 
is enlarged partly by the elevation of the ribs, the elasticity of 
their cartilages seems nearly of itself sufficient to restore the ribs 
to their former position : but of the mode in which the chest is 
enlarged in inspiration I shall have to speak again. 

The spine is composed of twenty -four bones, which together 
form a canal for the reception and protection of the spinal marrow. 
This is a beautiful stmcture, of which I could not give you a good 
idea without the assistance of plates ; but, whilst the spinal marrow 
is effectually protected, it is contained in a canal running through 
the whole spinal column, this column having considerable flexi- 
bility. This flexibihty is, however, made perfectly consistent with 
the avoidance of any injury to the spinal marrow ; and the object 
is chiefly obtained in this manner : that, although all the vertebrae 
have a certain degree of motion, j'et this is very small : so that 
the result is a great flexibility of the whole column, with very 



537 



little motion in any one part of it ; the greatest curve ever re- 
presented by the spinal marrow being very moderate in any 
one part, describing, in fact, but a very trivial aberration from a 
straight line. Between the bodies of the vertebrae, which are 
strongly bound together, there is a peculiar elastic material, facili- 
tating the motion and elasticity of the whole column ; there is 
nothing exactly like it in the body ; and we simply call it the interver- 
tebral substance. In some animals, and particularly in some fish, 
there are more extensive provisions of this kind, — fluid being inter- 
posed between the bodies of the vertebrae, so that the several parts 
of the colum ride, as it were, on a fluid, which yields in different 
directions according to the motions required by the animal. The 
mechanism by which the bones become subservient to the motive 
powers constitutes the various joints ; and of the general structure 
of these I next proceed to speak. First, the bones which are to be 
joined are formed into a convenient shape, this generally implying 
an extension of surface (articular surface) ; next, they are covered 
by a beautiful stratum of highly elastic material (gristle or carti- 
lage), over which a membrane passes, presently to be mentioned. 
The bones thus prepared are firmly bound together by very strong, 
inelastic, fibrous bands (ligaments), and then over the whole is 
thrown a sort of bag (the capsule), which includes the ends of 
the bones in one cavity. This bag is strengthened by numerous 
ligamentous fibres running over it. I must further observe that 
the whole interior of the joint is lined by a smooth membrane, 
which T have already mentioned as passing over the cartilage ; and 
it is from this membrane that the fluid is secreted which lubricates 
or oils the joint, as it were; and which, from its resemblance to 
white of egg, is termed the synovia, the membrane being called 
the synovial membrane. So that here you have bones for strength ; 
ligaments for security ; cartilage for elasticity, to prevent jarring 
in the rapid or rude motions required ; and oil for diminishing 
friction. 

A rude imitation of all this occurs in the patent axle, except 
that there is no contrivance for the continued supply of oil. Fur- 
ther, the ligaments are exquisitely contrived for the admission of 
all motion which the form of the bones is calculated to render se- 
cure, or the moving powers capable of impressing on them, whilst 
they powerfully oppose any other. The joints also have a very 
low degree of sensibility, in harmony with the rough impressions 
to which they are subjected : but all this is immediately changed 



538 



ou tlie occurrence of disease, when tlie whole apparatus becomef?, 
for reasons referred to in the foregoing work, exquisitely sensitive. 
The bones then give support; tliej afford firm points for the at- 
tachment and action of the muscles or moving powers, and form 
joints of the structure required for the various motions : some joints 
are ball and socket, and admit of a very extended sphere of motion, 
as those of the hip, and still more remarkably, the shoulder ; some 
are hinges, as the knee or elbow ; some allow only of a very little 
motion, as that of the collar-bone with the blade-bone, which move 
as if they were one piece ; but ail joints have the general properties 
of which 1 have spoken : and now we will consider the parts by 
which they are moved. 

MUSCLES*. 

The powers by which the body is moved, and by which the 
joints are made to execute tlie different motions for which they are 
mechanically adapted, are the muscles (the flesh of animals) ; and 
they are so constituted as to be in harmony with the joints on 
which they act. That is, they are so disposed, that, w^hilst they 
can impress such motions on the joints as the mechanism of these 
parts safely allows, they can, under ordinary circumstances, produce 
no other. 

If you examine a piece of flesh, }'0u find that it is made up of 
fibres ; but as these, however closely we may examine them, ap- 
pear to be composed of an aggregation or bundle of lesser fibres, 
so w^e are accustomed to speak of those which appear as fibres to 
the naked eye, as bundles, or fasciculi, as we term them. In man, 
and many other animals, they are, as you know, for the most part 
red ; in some animals they are, on the contrary, white ; and in 
others, again, some are red and others are white. 

Now, muscles have the curious property of contracting them- 
selves, that is, of shortening their fibres ; and, of course, when 
they do so, they must necessarily approximate their attachments ; 
so that, if you wish to know the action or mechanical use of a 
given muscle, you have only to ascertain which of its attach- 
ments is the fixed point, when its action is immediately determined. 



* Muscles contain gelatine, albumen, a peculiar matter called o.<mazome, and 
certain salts; but they arechietiy composed of the fibrin of the blood. 



539 



You must not, however, conclude that a fibrous structure is neces- 
sary to a power of this kind ; this is by no means proved ; for we 
find contraction taking place, and with the effect of locomotion in 
some lower animals, where we can by no means safely infer the ex- 
istence of a fibrous structure. So have we parts in the human body, 
of whose powers of contraction there can be no doubt, and yet 
in which we can hardly demonstrate a fibrous structure. Then, 
again, in some membranes, in ligaments and tendons, we have a 
very obvious fibrous arrangement, where we are tolerably certain 
that there exists no contractile power*. 

When a muscle acts (shortening itself, in fact"), it becomes very 
hard ; it feels as if its structure had become suddenly condensed, 
as it were, and the change from its previous flaccid and soft con- 
dition is very remarkable. Microscopically examined, it seems 
that the fibres thus shortened are thrown into waves, in a zigzag 
form. I must observe to you, that, in many instances, muscles of 
great bulk act on surfaces comparatively so small, that were the 
whole muscle fixed to the part on which it acts, it would embarrass 
its motions, and entirely change the symmetry of the body. Joints, 
for example, already representing certain enlargements in differ- 
ent parts, would then become, as it were, immense tumors, in the 
situation which they occupy. In these cases the fibres of the 
muscles are gathered into smaller space, and fixed to a cord, which 
is attached to the part intended to be moved ; and these cords are 
the tendons or sinews. 

A tendon is a whitish, glistening, cord-like body, extremely strong, 
very inelastic, and of a fibrous texture. Inelastic, because any 
elasticity would obviously weaken the power of the muscle ; since 
some of this would necessarily be spent in overcoming the elasticity 
of the cord, instead of the whole being applied in moving the part 
on which it acts. As the muscles act with great force, the sinews 



* It is very necessary that you should recollect these things ; for the notion that 
contraction implied the necessity of a fibrous or of a muscular texture, has formerly 
led to very unnecessary difficulty. You would be surprised at the absurdity which 
was broached at one time in regard to so common a phenomenon as the contraction 
of the pupil, merely because, at that period, men had not demonstrated the iris to 
be either muscular or fibrous ; and, at the removal of these difficulties, on finding 
that it had really a fibrous arrangement : although, as I have just said, the exa- 
mination of contractility, either in man, and still more in some of the lower 
animals, shews that contractility is by no means necessarily associated v/ith a 
muscular structure, nor even with one demonstrably fibrous. 



540 



on which thej pull must necess.irilj be strong, or else the muscles 
would be contmually snapping them ; as indeed they sometimes do, 
notwithstanding. They are, therefore, not so strong as the mus- 
cles, since the latter occasionally break them ; nor can we say 
that under every circumstance they are absolutely inelastic : but 
they appear to be so far so, that the force of the muscles is not 
sufficient to call their elasticity into play. In certain dislocations 
it seems reasonable to infer that the tendons are not entirely de- 
prived of elasticity, although the quantity is exceedingly small. 
Now the properties of all muscles are somewhat similar in kind ; 
but we observe very curious and interesting varieties in their 
development. I have said that they are of a fibrous texture ; that 
they have a power of contraction ; and I may now add, that they 
cannot contract continuously ; at least, we know of no example 
in which we do not observe alternations of contraction and re- 
laxation, although nothing can be more varied than the manner 
in which this is exemplified. 

Some muscles contract only for a very short period, and then 
relax again. The heart is an example of this kind ; this muscle, 
through life, exhibits a constant succession of contractions and 
relaxations, in rapid alternation. Some muscles again are ordi- 
narily in a more or less relaxed condition until they are required 
to perform their respective offices, when they contract, relax, again 
contract, and so on, as required : and as these are under the con- 
trol of the will, they are called voluntary muscles. Some again 
have this remarkable difference, that their ordinary condition is 
that of contraction, and their relaxation only occasional ; such are 
the sphincter muscles which close canals, as those placed at the 
neck of the bladder and the termination of the lower bowel. 

We observe remarkable differences in different muscles in re- 
lation to their subjection to the will of the individual. Some are, 
under ordinary circumstances, completely under the control of the 
will, others entirely out of its dominion ; and, again, some are nei- 
ther wholly subject to volition, nor altogether independent of it. All 
the muscles moving the various joints, those most directly con- 
cerned in moving one part on another, or in moving the body from 
place to place (locomotion), are under the control of the will ; so 
that if I wish to raise or depress my arm, or to go to the other end 
of the room or elsewhere, I feel that I have the power to do so ; but 
if I wish to stop the beating of my heart, or to suspend certain 
actions that are constantly taking place in the muscular coat 



541 



of the "alimentary canal, I have not the slightest power to do 
this. Then, in regard to my breathing, I observe the third case. 
If I wish to hold my breath, I can do this for a limited time, but 
still but for a short period ; so that my respiratory muscles are 
neither within my control, nor entirely out of it : and this is very 
beautiful. If I had no power over these muscles (chiefly the dia- 
phragm and abdominal muscles), all the other muscles would lose 
a great part of their function ; because, whenever I wish to use the 
arm or leg, or both, with the greatest force, I am obliged to fix the 
trunk, in order that the muscles moving the extremities may have 
a fixed point to act on. Now, this I do by the simultaneous action 
of these muscles, which are ordinarily occupied in carrying on 
respiration, during which their actions are alternate ; but when we 
fix the trunk, or exercise the function of straining, they act to- 
gether : on the other hand, were these muscles dependent on the 
will for their action, I should never be able to sleep safely ; because 
we know, that during sleep the voluntary muscles are in a state of 
repose ; which cannot be, of course, the case with the muscles of re- 
spiration, which, being independent of the will, carry on this func- 
tion safely through the night, enlarging the chest, for the reception of 
air, and again expelling it, as in the day. The modified influence 
which the will is capable of exerting over the muscles closing the aper- 
tures of the bladder and the rectum, are alike in harmony with the 
necessities and comforts of the oeconomy. Matters no longer ser- 
viceable to the body are allowed to accumulate to a certain extent, 
and we then have feelings soliciting their ejection : but now the 
will has a certain power, and very nicely limited ; contributing to 
our comfort and convenience on the one hand, without allowing a 
power the exercise of which would be prejudicial, on the other. 

There are a few other circumstances which, even in this sketch, 
I may mention. Muscles appear to be highly organized parts ; but 
they are not so sensitive as many others. They become strong and 
firm, and increase in bulk by exercise ; and, on the contrary, 
dwindle and become soft by inaction. This is seen alike in the 
highly developed muscles of those accustomed to labour, and in the 
opposite condition of those who are sedentary or inactive. Besides 
these modified exercises of volition, there are some others which 
are also interesting : thus, the muscle closing the eyelids is ordi- 
narily a voluntary muscle ; yet, if the eye be in danger, or subject 
to intense light, I close it without any distinct recognition of voli- 
tion, or I even close it involuntarily. So, after great fatigue, I may 



512 



wish to keep tlie eye open ; but the lid gradually drops, and sleep 
supervenes. There are certain muscles in the internal ear — in the 
tympanum, in fact, — over which it is certain that I exercise a voli- 
tion, but of a kind of which I am not sensible ; although the power 
I possess of modifying the effects of violent vibrations of air, or of 
rendering the organ susceptible of very feeble ones, shews that I 
have the power of relaxing or contracting the membrane which 
covers the tympanum (the parchment of the drum) at pleasure. 

I have already observed that muscles act with great force, and 
that, ordinarily, this is in harmony with the parts with which they 
are connected. But this harmony, and indeed any other of the 
characters of muscular action, may be changed by various circum- 
stances attending on accident or disease. To some of these I have 
already alluded in speaking of the sympathies of these parts. 
With regard to the force of muscles, they will sometimes snap their 
tendons, tear off the processes of bone, or break asunder those to 
which they are attached ; and, in certain cases, produce conse- 
quences still more serious. Thus, in great efforts, the pressure 
exerted by the diaphragm and abdominal muscles in fixing the 
trunk, will squeeze out the contents of the abdomen, causing what 
are commonly called hernise or ruptures : and, in certain acci- 
dents, where they act under the influence of alarm, they will pro- 
duce consequences still more frightful : thus, I have known this 
simultaneous action of the muscles of the abdomen and diaphragm 
compress the viscera so violently as to tear the liver. 1 recollect a 
man who fell from a suspended platform, on which he was cleaning 
the walls of a church. He stood too near the edge, and the plat- 
form swung away from the wall ; he fell, and received a very 
severe oblique fracture of his thigh ; this was put right, but he 
sunk and died ; and examination discovered an enormous rent in 
his liver, which might have fallen double the distance without 
injury. 

In these cases individuals instinctively struggle violently, and 
the actions of the muscles, I have mentioned, occasionally thus 
injuriously compress the viscera. I recollect that Mr. Abernethy 
used to tell us of a similar case to that which I have related. In 
the accident which occurred to the unfortunate gentleman who fell 
last year in the parachute, — a careful consideration of all the cir- 
cumstances leaves very little doubt, that so much of the extensive 
injury as referred to the ribs, resulted from muscular action ; 
since the other circumstances point ^'^ery clearly to the manner 



o48 



in which he must have fallen, and to the impossibility of the frac- 
ture of the ribs on both sides having been the effect of direct 
violence from the fall. I shall have occasion to mention the facts 
and reasonings to which this case leads, hereafter ; for they are 
exceedingly interesting. 

I must add a remark or two in regard to the abdominal muscles, 
and of the diaphragm. The abdominal muscles form the walls of 
the abdomen ; the diaphragm is a muscle which divides the chest 
from the abdomen, forming a sort of floor to the former and roof 
to the latter. The actions of these muscles are numerous and im- 
portant : the only one I shall particularly allude to, is that by 
which they conduct ordinary respiration. In inspiration the dia- 
phragm contracts the convex surface towards the chest, which, ren- 
dering it of course flatter, enlarges the cavity : the abdominal 
muscles yielding, as the diaphragm, thus descending, displaces the 
viscera beneath it. The chest thus enlarged, air rushes in by the 
windpipe, and fills the chest ; now- the abdominal muscles, con- 
tracting in their turn, force up the diaphragm into its former 
condition, thus expelling the air again from the lungs, performing 
the act of expiration. Xow^ there are many subsidiary powers, 
which are occasionally put in requisition in breathing, and many 
wdiich habitually contribute more or less towards it : but still, under 
ordinary circumstances, respiration is chiefly performed by the al- 
ternate contractions of the abdominal muscles and diaphragm : 
and, as I have said before, when we exert the act of straining, 
these powers act together, and we feel that we must hold our breath 
whilst they continue to do so. I must not, however, say more on 
the subject of muscles in this place. 



OF MEMBRANES. 

The notion of a membrane is best conveyed by referring at 
once to a familiar example, for which I may suppose the bladder 
of a sheep or any other animal ; not that membranes always form 
sacs, or that they are always as thick as the example quoted, which 
has other structures laid upon it ; but as representing a thin stratum 
of animal matter. Now membranes have difl'erent characters. 
Those lining the chest and abdomen are examples of serous mem- 
branes: and we have other examples of them in the brain and 
elsewhere ; but it will be sufficient if I give you a general idea of 



5i4 



their arrangement in the chest or abdomen. When you see either 
of these cavities opened in a sheep, ox, or any other animal, you 
perceive that the surfaces exposed are very smooth ; this surface is 
the serous membrane of such cavities ; and they are all disposed in 
the following manner. 

imagine that you have to line a box or other cavity with gold- 
beater's skin, or any other transparent material, and that your 
object was not only to line the box, but at different parts to throw 
a fold over some article which was to be contained in the box, and 
then carry the lining so thrown over the article back to the point 
up to which you had so far attached the lining ; you would thus 
line the box and cover the article contained in it with the same 
material ; so that each article in the box would be maintained in 
its situation by the fold of lining which you had thrown over it. 
If therefore you were again to remove the lining from off the dif- 
ferent articles, they would all fall to the bottom, or out of the box, 
were it open, because you have kept them by this plan really on the 
outside of the lining. Supposing also that you had secured some 
articles so close to the box as to allow of little motion— some of 
much greater ; it would follow that the meeting of the lining after 
it had been thrown over the different articles, and carried back to 
the point where you thew the fold, would be longer or shorter, ac- 
cording as you had tied the articles more closely, or left them more 
or less hanging loosely in the box. 

Now, if you understand this, you will at once comprehend the 
disposition of the serous membranes, which are just arranged in 
this manner. The abdomen is lined hy the smooth serous mem- 
brane (the peritonaeum), and this is thrown over the various viscera 
so as to constitute their external covering, and to form part of their 
structure (their peritoneal coat). The viscera are more or less 
closely connected to the posterior surfaces of the cavity, and these 
loose processes of the lining membrane, in the folds of which the 
viscera are included, are called by certain names : — thus, that which 
retains the small intestines in their situation is the mesentery ; that 
containing the colon, the meso-colon ; and so on of the different 
bowels (meso-csecum, meso-rectum). Sometimes they are called, 
from their immediate offices, ligaments: — thus we speak of the li- 
gaments of the liver, which are formed in the same manner. 
The serous membrane of the chest is called the pleura ; the cavity 
being lined by a membrane which is thrown over the lungs in the 
same manner, sustaining them in position, and giving them the 



close polished covering which they present on examination. The 
pericardium is disposed in the same manner, only that there is a 
bag formed, besides the close covering immediately investing the 
heart ; and on the outer side of this bag there is a membrane of 
another kind, of a firm and unyielding texture, and not transpa- 
rent, but thick and fibrous (a fibrous membrane). The serous mem- 
branes have, under ordinary circumstances, but a low degree of 
sensibility ; but, like most other structures so circumstanced, be- 
come acutely painful in disease, especially in inflammation. They 
are transparent, elastic, and present a beautifully smooth and po- 
lished surface ; and the motion of the different parts of this surface 
in each other is facilitated by an exhalation (which renders it more 
or less slippery) of serous fluid. 

Another kind of membrane is the mucous ; these line canals, as 
the nose, mouth, fauces, alimentary canal, the urinary organs, the 
windpipe and its ramifications, &c. They are therefore in the form 
of tubes ; they secrete a slippery sort of fluid, which lubricates the 
parts. Mucous membranes are somewhat elastic, like the serous, 
and have some other peculiarities, which have already been spoken 
of in the preceding pages. Sometimes they are associated with 
serous membranes, as in the function of the stomach and bowels ; 
thus these parts are composed, externally, of the serous membrane 
(the peritonaeum), — internally, of a mucous membrane. Between 
these, muscular fibres are interspered, forming the muscular coat 
of the organ : so that you have externally a serous, next a mus- 
cular, and internally a mucous coat ; and these are united by a 
substance which I shall immediately speak of under the name of 
cellular tissue. One other sort of membrane I have yet to men- 
tion ; this is the fibrous. These membranes, as their name im- 
plies, exhibit an arrangement of fibres. They are very firm, 
strong, and inelastic. The periosteum, which covers the bones ; 
the fasciee, which bind down the muscles ; the outer, or bag-like 
portion of the pericardium ; the dura mater, which lines the interior 
surface of the scull ; are examples of this structure. Sometimes 
these are lined by serous membranes, as the dura mater and peri- 
cardium : sometimes they adhere more or less closely to the parts 
which they cover, as the fasciae and periosteum ; their general cha- 
racter being those w^hich I have mentioned. 



N N 



540 



CELLULAR TISSUE. 



When yon look at the under part of a shoulder of veal or 
mutton, you observe a portion of flesh but loosely connected with 
the parts on which it lies by a stringy^ extensile, and somewhat 
elastic matter. This is what we call cellular tissue, — cellular, be- 
cause we find that it consists of a series of cells, which, under 
ordinary circumstances, communicate with each other. This cel- 
lular tissue in an animal body is roughly represented by the mortar 
in a building, but with some important differences, presently to be 
mentioned. Like the mortar, however, it serves as a connecting 
medium of all parts with those contiguous to them, and hence it is 
found in all parts of the body ; but here the analogy ceases. In 
the body, this connecting medium is very differently disposed, ac- 
cording to the functions which such parts are to execute. In some 
it allows of very free motion between the parts which it connects ; 
whilst, by its elasticity, it readily allows of the return of such parts 
to their more ordinary respective positions. In other parts, where 
the motion is less, the cellular tissue becomes more dense, its fibres 
shorter : and again, where parts are to move in concert, as one 
piece, it is so close and dense as to form a very strong connecting 
medium, allowing of no motion whatever between them. The 
cellular tissue is primarily, therefore, employed in connecting va- 
rious parts with each other, and in allowing, in some cases, such 
motion as is convenient and safe in the exercise of the several 
functions of the parts which it connects. In others, in preventing, 
by its close texture, any motion whatever between them. You 
thus perceive that, if it become changed in its structure, it will 
embarrass all parts between which it should allow any freedom 
of motion, although it may not necessarily interfere with their move 
essential functions. 

I have said that this tissue is cellular, the cells communicating 
with each other ; and, where it is arranged in a loose manner, as 
that beneath the skin, for example, this may be demonstrated by 
the impulsion of air into it. Butchers, when they kill calves, in- 
flate the cellular tissue by impelling air underneath the skin, so 
that the whole body of the animal appears inflated. Accident 



547 



sometimes produces a similar result in the human body. In some 
cases of fractured ribs, the rough surface of the broken bone pro- 
duces abrasion of the lungs ; the consequence is, that, as respiration 
proceeds, a certain portion of the air escapes through the abraded 
lung, and into the cellular tissue, and this gradually inflates the 
chest, face, and other parts, in a very frightful manner. 

The cellular tissue, as has been already observed, becomes the 
frequent seat of diseased actions ; whether these be of the more 
active kinds, which we usually include under the different kinds of 
inflammations, or those which are attended by gradual diseased 
depositions, which either thicken parts, or forms the various tu- 
mours. Nature appears to determine morbid actions here, because 
they are less injurious than they are commonly found to be in other 
structures. Like all parts, the cellular tissue is moistened by a 
fluid, and the diseased increase of this forms the water of general 
dropsy. 

You will find some other remarks on cellular tissue in connec- 
tion with the Discourse on Sympathy, and I shall have occasion 
hereafter to return more than once to this structure, in considering 
different diseases. 

NERVOUS SYSTEM. 

The simplest idea of the nervous system is conveyed, I think, 
by remarking, first, the general and obvious physical characters of 
the brain, spinal marrow, and nerves, and then stating the general 
natirre of their functions. The nervous system, then, in its physical 
character, may be regarded as representing, generally, a soft, animal 
substance, of w^hich the brain is an example, which, in some modi- 
fication of form or other, pervades every part of the body, and 
which is inclosed in membranes which appear to exercise the func- 
tion of keeping together the matter so disposed, and, in some mea- 
sure, protecting it from injury. The nervous matter is sometimes 
disposed in large masses, as the brain, or in very small knot-like 
productions, technically called ganglia ; sometimes in cord-like pro- 
longations, like the spinal marrow, or the larger nerves ; and some- 
times in fine threads or filaments, like the smaller nerves. All 
nerves communicate either directly or indirectly with the brain, the 
spinal marrow, and Vv'ith each other : so that, were the nervous 



548 



system presented to you apart from otlier structures, it would repre- 
sent a large mass of nervous matter in the situation of the head ; a 
long- cord in the line of the back ; and an inextricable sort of net- 
work extending from these points to all parts of the body, repre- 
senting this net-work traversed in different parts by larger cords 
representing the large nerves. You would also observe some nerves, 
like the great sympathetic, representing a series of knots or ganglia, 
having communications, in different parts of its coarse down the 
sides of bodies of the vertebrae, with branches derived from the 
brain and spinal marrow. 

Now, the functions of the nerves are nothing less than the 
means through which we become acquainted with surrounding 
objects, by which all the organs of the body are so associated as to 
form one machine, and by which the various offices and uses to 
which they are destined — functions, as we call them — are executed. 
In a general sense, you may regard the nerves as follows : — 

That extremity most remote from the brain is the collector of im- 
pressions, as tcuch, taste, smell, and so on ; the cord which extends 
from this to the brain is the messenger which conveys such impres- 
sions ; and the brain or spinal marrow, the part, through some 
mysterious action of which we become conscious of such impres- 
sions, to which w^e give those names which I have mentioned, or 
any other, according to the sensations received. Thus the senses 
of touch, taste, smell, hearing, and seeing, result from certain im- 
pressions made by the mechanical properties of bodies, by some 
property of a more refined kind — by light, and vibrations of air, on 
the minute terminations of the nerves distributed to the skin, the 
tongue, the nose, the eye, and the ear, respectively. These impres- 
sions are communicated to the brain, on which the sense or per- 
ception ultimately depends. To all correct sensation these several 
phenomena are necessary : that is, impression on the extreme 
branches, communication along the trunk of the nerves, and certain 
actions in certain parts of the great nervous masses constituting the 
brain or spinal marrow. The exercise of the will to move any part 
depends also on certain nervous communications between that part 
and the brain being uninterrupted ; for, although it does not follow 
that volition should necessarily be present, such communications re- 
maining entire, yet it is certainly absent if these be disjoined; for 
certain disorders may prevent this, wdiich either refer to the 
extreme branches of this nerve in the part supplied, or in the brain 



549 



or spinal marrow in which such nerve may terminate, or whence it 
may issue. Then the brain and spinal marrow hold commnnica- 
tions, as it were, of a secret nature, with many parts of the body, 
which, in states of health, afford us no sensation recognizing what is 
is going- on in the part. Thus I am not sensible of the blood's rapid 
current through the various organs of my body ; I have no sensa- 
tion informing me directly that digestion, the secretion of bile, &c. 
are going on in a natural and healthy manner. By experience, 
indeed, I acquire a very interesting degree of knowledge on these 
subjects, which, however, it is difficult to describe by any expres- 
sion of sensation. When these organs are disordered, I feel the 
absence of comfort in a thousand ways ; and 1 learn to appreciate 
the advantage, and in some sense to recognize the sensations, of 
healthy action, in the general, but still expressive terms, of health, 
comfort, and vigour. 

It is an interesting thing to remark, that all organs, whose daily 
and constant exercise is essential to the life of the body, are placed 
thus out of the sphere of the will and of ordinary sensation ; and that 
the supply of nerves to them are characterized by the greater or less 
connection of such nerves with those having in them gangha or 
knots, of which I have spoken. Thus I can by my will neither 
directly influence respiration, the circulation, digestion, the secretion 
of the bile, nor the action of the bowels : so that the basis of the 
body's safety, and of the mind's moral security, though in neither 
case prohibitory of a responsible abuse, seem placed out of the 
sphere of ordinary volition : for in the mind I can will to do right 
or wrong, but I cannot will away the intuitive general perception 
of what is right and wrong. Different parts of the nervous system 
execute different functions ; some nerves being nerves of motion, 
some of sensation, and this may be either common sensation, as we 
term it, or those by which we recognize light, sound, flavour, and 
so forth. 

The nervous system, as you perceive, is therefore the governing 
power of all the actions of the body, and it is visibly developed, in 
a more or less simple form, in almost all creatures which are not 
too minute for our investigation . In man, however, it is very com- 
plex ; but the brain is the sentient centre to which every thing is 
ultimately referred. If the communication be cut off with the brain, 
the function of the part thus disjoined is, for the most part, ab- 
rogated; whilst, if the brain itself be materially injured in that part 



550 



with wliicli the nerves more directly commiuiicate, the actions of 
life cease altogether. The brain, however, has various functions of 
a still more wonderful kind, which are somehow or other associated 
with it; but I have already observed as much on this subject as is 
necessary for our object, in the conclusion of the Discourses on 
Sympathy. The brain and nerves, like all other parts, are supplied 
with vessels, absorbents, and the necessary apparatus of a living 
structure ; so that they undergo various diseased changes, like all 
other structures. 

I have thus endeavoured to give you a faint sketch, a very 
general idea, of the body. I had fully intended to have made it 
more complete ; but I found this objectionable on account of the 
increase of bulk and price which it would necessarily have occa- 
sioned. 

After all, however, it may answer the purpose above stated. 
You will recollect that when we say this or that part is chemically 
composed of this and that principle, we only mean, proximately ; 
that is, that the putting together of these principles is the nearest 
step to the structure which they form. In this light, the body 
appears to be made up of a great variety of things ; but if these be 
traced to their elements, we find them to be very few. We say that 
water, for example, exists here and there : you see how large a pro- 
portion of the blood is formed by this fluid ; but this fluid itself, you 
know^, is only formed by oxygen and hydrogen in certain propor- 
tions, and these principles are ibund in the body, not necessarily in 
the ibrm of water. So, when we speak of albumen, or gelatine, the 
one as being coagulated by a certain heat, as by hot water, the other 
as dissolving in it, we speak of different ibrnis of animal matter: 
but all animal matter, if its analysis be continued so as to resolve 
it into its ultimate principles, is found to consist essentially of four 
elements, in various degrees of combination ; these elements being 
carbon, hydrogen, nitrogen, and oxygen. We find, however, small 
proportions of sulphur, iron, and certain salts, added to some animal 
matters ; but the essential elements are those which I have men- 
tioned. 

You should also remember that all parts of the body are pro- 
vided with vessels to supply the blood, and to convert it to the 
structure required, with vessels to return the superfluous blooc', 
with absorbents to carry away the old material, with organs to 
separate and eject it from the body, with nerves to give the 



551 



several parts their vital powers, and with cellular tissue to con- 
nect the w^hole together ; so that every part is made up of arteries, 
veins, absorbents, nerves, cellular tissue, and the peculiar matter of 
which the part is composed. In many instances, the part appears 
to consist of nothing else but the ramifications of the different ves- 
sels and nerves which I have mentioned ; further, you should never 
forget that every part of the body forms but a portion of one ma- 
chine, everywhere furnished with powers of resisting, in a certain 
degree, injurious influences, or of repairing the mischief which 
they may have produced, and between all parts of w^hich there is 
a correspondence and a concert of action, by means of the nervous 
S}'stem, which subjects the whole body to common laws, and renders 
it one harmonious creation. 



FINIS. 



i'lUNrCO BV J. MALLEIT, VVARDOr,R STREE 1", SOHO, LONDON. 



BY THE SAME AUTHOR. 



ON THE UNITY OF THE BODY, 

Being an application of the Phenomena of SY'MPATHY to the 
Improvement of the Constitutional Treatment of Local Diseases. 



PRACTICAL DIRECTIONS TO FACILITATE 

THE 

DISTINCTION OF HERNIA x\ND OTHER 
TUMOURS OCCURRING IN THE 
VICINITY OF THE GROIN. 
With REMARKS on TRACHEOTOMY", as applied to the 
Treatment of Severe Cases of CHRONIC LARYNGITIS ; 
with Cases. 



A PRACTICAL TREATISE 

ON 

STRICTURE OF THE URETHRA; 

The object being to adapt the various Modes of Treatment 
recommended bv different Surgical Writers, to their 

appropriate Cases ; with Remarks on 
STRICTURE OF THE RECTUM AND OESOPHAGUS. 



CLINICAL OBSERVATIONS 

ON THE CONSTITUTIONAL OIIIGIN OF THE 

VARIOUS FORMS OF PORRIGO, 

Commonly called Ringworm, Tinea, Scald- Head, &c. with 
Directions for the more Scientific and Successful Treatment 
of this hitherto obstinate Class of Diseases. 



*^* For Notices of these "Works, see Cooper^ s Surgical Dictionary ; Med. Chir. 
Review; Foreigyi Quarterly Journal of Med. Scieiice ; Edi?ib. Med. and 
Surg. Journal ; London Med. and Szirg. Journal ; Lancet ; and most other 
Medical Periodicals of the years 1824-5, 1830-1, 1834-5. 



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